Fundamentals Of Nursing NCLEX Quiz 50

1. A newly RN nurse is about to insert a nasogastric tube to a client with Guillain-Barre Syndrome. To determine the accurate measurement of the length of the tube be inserted. the nurse should:

The correct answer is to place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. This is the correct method for determining the accurate measurement of the length of the nasogastric tube to be inserted. The xiphoid process is a reliable anatomical landmark that indicates the correct placement of the tube in the stomach. Placing the tube at the base of the nose or measuring down to the top of the sternum would not provide an accurate measurement for insertion.

Explanation

The correct answer is to place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. This is the correct method for determining the accurate measurement of the length of the nasogastric tube to be inserted. The xiphoid process is a reliable anatomical landmark that indicates the correct placement of the tube in the stomach. Placing the tube at the base of the nose or measuring down to the top of the sternum would not provide an accurate measurement for insertion.

2. A stroke client who was initially on NGT feeding was able to tolerate soft diet so the physician ordered for the removal of it. The nurse would instruct the client to do which of the following before he removes the tube?

Inhale and exhale simultaneously.

Take a long breath and hold it.

Do a Valsalva maneuver.

Blow the nose.

Holding the breath closes the glottis hence it will be easier to withdraw the tube through the esophagus into the nose. and this method will also prevent aspiration.

Explanation

Holding the breath closes the glottis hence it will be easier to withdraw the tube through the esophagus into the nose. and this method will also prevent aspiration.

3. After the client had tolerated the weaning process. the physician ordered the removal of the endotracheal tube and will be shifted into a nasal cannula. Which of the following findings after the removal requires immediate intervention by the physician?

Sore throat.

Hoarseness of the voice.

Coughing out blood.

Neck discomfort.

A sign of a tracheal or esophageal perforation which prevents oxygen from reaching the lungs and can result in internal bleeding. This life-threatening side effect of being intubated requires immediate medical intervention.Options A. B. and D are normal and that the client should limit talking if it occurs.

Explanation

A sign of a tracheal or esophageal perforation which prevents oxygen from reaching the lungs and can result in internal bleeding. This life-threatening side effect of being intubated requires immediate medical intervention.Options A. B. and D are normal and that the client should limit talking if it occurs.

4. Before feeding a client via NGT. the nurse checks for residual and obtains a residual amount of 90ml. What is the appropriate action for the nurse to take?

Discard the residual amount.

Hold the due feeding.

Skip the feeding and administer the next feeding due in 4 hours.

Reinstill the amount and continue with administering the feeding.

If the residual feeding is less than 100ml. feeding is administered.

Explanation

If the residual feeding is less than 100ml. feeding is administered.

5. A nurse is checking the nasogastric tube position of a client receiving a long term therapy of Omeprazole (Prisolec) by aspirating the stomach contents to check for the PH level. The nurse proves that correct tube placement if the PH level is?

7.75.

7.5.

6.5.

5.5.

Gastric placement is indicated by a pH of less than 4. but may increase to between pH 4-6 if the patient is receiving acid-inhibiting drugs.

Explanation

Gastric placement is indicated by a pH of less than 4. but may increase to between pH 4-6 if the patient is receiving acid-inhibiting drugs.

6. Continuous type of feedings is administered over a __ hour period.?

4

12

24

36

Continuous feeding is administered for 24 hours. An infusion pump regulates the flow.

Explanation

Continuous feeding is administered for 24 hours. An infusion pump regulates the flow.

7. Which of the following is not true regarding the types of a nasogastric tube?

Cantor tube is a single-lumen long tube with a small inflatable bag at the distal end.

Miller-Abbott tube is a long double-lumen used to drain and decompress the small intestine.

Levin tube is a double lumen nasogastric tube with an air vent.

Sengstaken-Blakemore tube is a three-lumen tube.

A levin tube is a single lumen nasogastric tube while a Salem sump tube is the double lumen nasogastric tube with an air vent.

Explanation

A levin tube is a single lumen nasogastric tube while a Salem sump tube is the double lumen nasogastric tube with an air vent.

8. A client is subjected to undergo a chest x-ray to confirm the endotracheal tube placement. The tube should be how many centimeters above the carina?

2-4 cm.

1.5-3 cm.

1-2 cm.

0.5-1 cm.

Placement of an endotracheal tube is confirmed by a chest x-ray and the correct placement is 1 to 2 cm above the carina.

Explanation

Placement of an endotracheal tube is confirmed by a chest x-ray and the correct placement is 1 to 2 cm above the carina.

9. The nurse is preparing to give bolus enteral feedings via a nasogastric tube to a comatose client. Which of the following actions is an inappropriate practice by the nurse?

If bowel sounds are absent. hold the feeding and notify the physician.

Assess tube placement by aspirating gastric content and check the PH level.

Warm the feeding to room temperature to prevent the occurrence of diarrhea and cramps.

Elevate the head of the bed to 45 degrees and maintains for 30 minutes after instillation of feeding.

If the client is comatose. place in a high-fowlers which is in a 90-degree level.

Explanation

If the client is comatose. place in a high-fowlers which is in a 90-degree level.

10. The nurse is assessing a client with an endotracheal tube and observes that the client can make verbal sounds. What is the most likely cause of this?

This is a normal finding.

There is a leak.

There is an occlusion.

The endotracheal tube is displaced.

When conducting the minimal leak technique the client should not be able to make verbal sounds or no air should be felt coming out of the client’s mouth.

Explanation

When conducting the minimal leak technique the client should not be able to make verbal sounds or no air should be felt coming out of the client’s mouth.