Fundamentals of Nursing Exam 2
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1. 1) The nurse is inserting a d
nasogastric tube in an adult Rationale: During the insertion of the naso-
client. During the procedure, gastric tube, if the client experiences diffi-
the client begins to cough and culty breathing or any respiratory distress,
has udifficulty ubreathing.uWhat uis uwithdraw uthe utube uslightly, ustop uthe utube
the umost uappropriate uaction? advancement, uand uwait uuntil uthe udistress
a. Insert uthe utube uquickly. usubsides. uIt uis unot unecessary uto unotify
b. Notify uthe uhealth uthe uHCP uimmediately uor uremove uthe utube
ucare uprovider ucom- upletely. uQuick uinserting uthe utube uis
uimmediately. unot uan uappropriate uaction ubecause, uin
c. Remove uthe utube uand urein- uthis usitua- ution, uit uis ulikely uthat uthe utube
usert uit uwhen uthe urespiratory uhas uentered uthe ubronchus.
udis- utress usubsides.
d. Pull uback uon uthe utube
uand uwait uuntil uthe
urespiratory udis- utress
usubsides.
2. 2) uThe unurse ureceives ua utele- a
uphone ucall ufrom uthe upost Rationale:uThe ufirst uaction uof uthe unurse uis
uanes- uthesia ucare uunit uto uassess uthe upatency uof uthe uairway uand
ustating uthat ures- upiratory ufunction. uIf uthe uairway uis unot
a uclient uis ubeing utransferred upatent, uthe unurse umust utake uimmediate
uto uthe usurgical uunit.uThe umeasures ufor uthe usurvival uof uthe uclient.
unurse uThe unurse uthen utakes uvital usigns ufollowed
plans uto utake uwhich uaction uby uchecking uthe udressing uand uthe utubes
ufirst uon uarrival uof uthe uclient? uor udrains.uThe uother unursing uactions
a. Assess uthe upatency uof ushould ube uperformed uafter ua upatent
uthe uairway uairway uhas ubeen uestablished.
b. Check utubes uor udrains ufor
upa- utency
c. Check uthe udressing uto
uassess ufor ubleeding
d. Assess uthe uvital usigns
to ucompare uwith
upreoperative umeasurements
3. 3) uThe unurse uis u administering uthe uenema, uthe
uadministering ua ucleansing
uenema uto ua uclient uwith ua
ufecal uimpaction. uBefore
, Fundamentals of Nursing Exam 2
Study online at https://quizlet.com/_g0yh9w
a uleft uSims' uposition uso uthat uthe uenema
Rationale: uFor uadministering uan usolution ucan uflow uby ugravity
uenema, uthe uclient uis uplaced uin ua
nurse ushould uplace uthe uclient uin uin uthe unatural udirection uof uthe ucolon. uThe
which position?
, Fundamentals of Nursing Exam 2
Study online at https://quizlet.com/_g0yh9w
a. Left uSims' uposition head uof uthe ubed uis unot uelevated uin uthe
b. Right uSims' uposition uSims'
c. On uthe uleft uside uof uthe position.
ubody, uwith uthe uhead uof uthe
ubed uelevat- ued u45 udegrees
d. On uthe uright uside uof uthe
ubody, uwith uthe uhead uof uthe
ubed uelevat- ued u45 udegrees.
4. 4) uThe unurse uis upreparing uto c
uin- usert ua unasogastric utube Rationale: uDuring uinsertion uof ua unasogastric
uinto ua uclient. uThe unurse utube, uthe uclient uis uplaced uin ua usitting uor
ushould uplace uthe uclient uin uhigh uFowler's uposition uto ufacilitate
uwhich uposition ufor uinsertion? uinsertions uof uthe utube uand ureduce uthe
a. Right uside urisk uof upulmonary uaspiration uif uthe uclient
b. Low uFowler's ushould uvomit. uThe uright uside, uand ulow
c. High ufowler's uFowler's uand usupine upo- usitions uplace uthe
d. Supine uwith uthe uhead uflat uclient uat urisk ufor uaspiration; uin uaddition,
uthese upositions udo unot ufacilitate uinsertion
uof uthe utube.
5. 5) uThe unurse uis upreparing uto a, ub, uc, ue
uadminister umedication uusing Rationale: uBy uaspirating ustomach
ua uclient's unasogastric utube. ucontents, uthe uresidual uvolume ucan ube
uWhat uactions ushould uthe udetermined, uand uthe upH uchecked.uA upH
unurse utake ubefore uless uthan u3.5 uver- uifies ugastric uplacement.
uadministering uthe umed- uThe usuction ushould ube uturned uoff ubefore
uication? uSelect uall uthat uthe utubing uis udiscon- unected uto ucheck
uapply. ufor uresidual uvolume; uin uad- udition,
a. Check uthe uresidual uvolume usuction ushould uremain uoff ufor u30 uto u60
b. Aspirate uthe ustomach uminutes ufollowing umedication uadminis-
ucon- utents utration uto uallow ufor umedication
c. Turn uoff uthe usuction uto uabsorption. uThere uis uno uneed uto uremove
uthe unasogastric utube uthe utube uand
d. Remove uthe utube uand uplace uit uplace uit uin uthe uother unostril uin uorder uto
uad-
in uthe uother unostril minister ua ufeeding;uin ufact, uthis uis uan
e. Test uthe ustomach uinvasive uprocedure uand uis uunnecessary.
ucontents ufor ua upH
uindicating uacidity
6. 6) uThe unurse uis upreparing uto uad- uminister umedication uthrough ua
, Fundamentals of Nursing Exam 2
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u nasogastric utube uthat uis ucon- c
Rationale: uIf uthe uclient uhas ua unasogas-
utric utube uconnected uto usuction, uthe
unurse
Study online at https://quizlet.com/_g0yh9w
1. 1) The nurse is inserting a d
nasogastric tube in an adult Rationale: During the insertion of the naso-
client. During the procedure, gastric tube, if the client experiences diffi-
the client begins to cough and culty breathing or any respiratory distress,
has udifficulty ubreathing.uWhat uis uwithdraw uthe utube uslightly, ustop uthe utube
the umost uappropriate uaction? advancement, uand uwait uuntil uthe udistress
a. Insert uthe utube uquickly. usubsides. uIt uis unot unecessary uto unotify
b. Notify uthe uhealth uthe uHCP uimmediately uor uremove uthe utube
ucare uprovider ucom- upletely. uQuick uinserting uthe utube uis
uimmediately. unot uan uappropriate uaction ubecause, uin
c. Remove uthe utube uand urein- uthis usitua- ution, uit uis ulikely uthat uthe utube
usert uit uwhen uthe urespiratory uhas uentered uthe ubronchus.
udis- utress usubsides.
d. Pull uback uon uthe utube
uand uwait uuntil uthe
urespiratory udis- utress
usubsides.
2. 2) uThe unurse ureceives ua utele- a
uphone ucall ufrom uthe upost Rationale:uThe ufirst uaction uof uthe unurse uis
uanes- uthesia ucare uunit uto uassess uthe upatency uof uthe uairway uand
ustating uthat ures- upiratory ufunction. uIf uthe uairway uis unot
a uclient uis ubeing utransferred upatent, uthe unurse umust utake uimmediate
uto uthe usurgical uunit.uThe umeasures ufor uthe usurvival uof uthe uclient.
unurse uThe unurse uthen utakes uvital usigns ufollowed
plans uto utake uwhich uaction uby uchecking uthe udressing uand uthe utubes
ufirst uon uarrival uof uthe uclient? uor udrains.uThe uother unursing uactions
a. Assess uthe upatency uof ushould ube uperformed uafter ua upatent
uthe uairway uairway uhas ubeen uestablished.
b. Check utubes uor udrains ufor
upa- utency
c. Check uthe udressing uto
uassess ufor ubleeding
d. Assess uthe uvital usigns
to ucompare uwith
upreoperative umeasurements
3. 3) uThe unurse uis u administering uthe uenema, uthe
uadministering ua ucleansing
uenema uto ua uclient uwith ua
ufecal uimpaction. uBefore
, Fundamentals of Nursing Exam 2
Study online at https://quizlet.com/_g0yh9w
a uleft uSims' uposition uso uthat uthe uenema
Rationale: uFor uadministering uan usolution ucan uflow uby ugravity
uenema, uthe uclient uis uplaced uin ua
nurse ushould uplace uthe uclient uin uin uthe unatural udirection uof uthe ucolon. uThe
which position?
, Fundamentals of Nursing Exam 2
Study online at https://quizlet.com/_g0yh9w
a. Left uSims' uposition head uof uthe ubed uis unot uelevated uin uthe
b. Right uSims' uposition uSims'
c. On uthe uleft uside uof uthe position.
ubody, uwith uthe uhead uof uthe
ubed uelevat- ued u45 udegrees
d. On uthe uright uside uof uthe
ubody, uwith uthe uhead uof uthe
ubed uelevat- ued u45 udegrees.
4. 4) uThe unurse uis upreparing uto c
uin- usert ua unasogastric utube Rationale: uDuring uinsertion uof ua unasogastric
uinto ua uclient. uThe unurse utube, uthe uclient uis uplaced uin ua usitting uor
ushould uplace uthe uclient uin uhigh uFowler's uposition uto ufacilitate
uwhich uposition ufor uinsertion? uinsertions uof uthe utube uand ureduce uthe
a. Right uside urisk uof upulmonary uaspiration uif uthe uclient
b. Low uFowler's ushould uvomit. uThe uright uside, uand ulow
c. High ufowler's uFowler's uand usupine upo- usitions uplace uthe
d. Supine uwith uthe uhead uflat uclient uat urisk ufor uaspiration; uin uaddition,
uthese upositions udo unot ufacilitate uinsertion
uof uthe utube.
5. 5) uThe unurse uis upreparing uto a, ub, uc, ue
uadminister umedication uusing Rationale: uBy uaspirating ustomach
ua uclient's unasogastric utube. ucontents, uthe uresidual uvolume ucan ube
uWhat uactions ushould uthe udetermined, uand uthe upH uchecked.uA upH
unurse utake ubefore uless uthan u3.5 uver- uifies ugastric uplacement.
uadministering uthe umed- uThe usuction ushould ube uturned uoff ubefore
uication? uSelect uall uthat uthe utubing uis udiscon- unected uto ucheck
uapply. ufor uresidual uvolume; uin uad- udition,
a. Check uthe uresidual uvolume usuction ushould uremain uoff ufor u30 uto u60
b. Aspirate uthe ustomach uminutes ufollowing umedication uadminis-
ucon- utents utration uto uallow ufor umedication
c. Turn uoff uthe usuction uto uabsorption. uThere uis uno uneed uto uremove
uthe unasogastric utube uthe utube uand
d. Remove uthe utube uand uplace uit uplace uit uin uthe uother unostril uin uorder uto
uad-
in uthe uother unostril minister ua ufeeding;uin ufact, uthis uis uan
e. Test uthe ustomach uinvasive uprocedure uand uis uunnecessary.
ucontents ufor ua upH
uindicating uacidity
6. 6) uThe unurse uis upreparing uto uad- uminister umedication uthrough ua
, Fundamentals of Nursing Exam 2
Study online at https://quizlet.com/_g0yh9w
u nasogastric utube uthat uis ucon- c
Rationale: uIf uthe uclient uhas ua unasogas-
utric utube uconnected uto usuction, uthe
unurse
