Ncm102 Skills Lab Evaluation Exam For Groups 19,36,15,22,40,23 (Afternoon)

To administer feedings to a client who cannot eat or have high risk for aspiration,

To suction stomach contents to prevent distention, remove stomach content for analysis,

Wash the stomach in case of poisoning and to administer medication.

All of the above

High fowler’s

Sitting, neck flexed

Anatomical position

Supine

Use penlight to observe for intactness of the nostril, ask the client to breath and then listen on which nares is more patent, then insert in the less patent

Use penlight to observe for intactness of the nostril, ask the client to breath and then listen on which nares is more patent and insert in the more patent nares

Whichever nares may be used in insertion

If the client refused to have it inserted then the nurse can insert it via the mouth.

Return to the manufacturer, it is defective

Put a stylet guide inside the tube while inserting it

Place on ice

No intervention needed

From the earlobe to the tip of the nose to the xiphoid process

From the earlobe to the tip of the nose to the midway between umbilicus and the xyphoid process

From the tip of the nose to the earlobe to the xiphoid process

From the tip of the nose to the earlobe to the midway between the umbilicus and xiphoid process

Oil-based lubricant

PNSS

Alcohol- based lubricant

Water- based lubricant

Hyperextend the client’s neck and advance the tube, when you observe gag reflex, tilt head forward and swallow.

Hyperflexed the client’s neck and advance the tube, when you observe gag reflex, tilt head forward and swallow.

Extend the client’s neck and advance the tube, when you observe gag reflex, tilt head forward and swallow.

Flex the client’s neck and advance the tube, when you observe gag reflex, tilt head forward and swallow.

Introduce 5-20 cc of air and auscultate for the gurgling sound

Have the patient sent to the radiology department for X-ray

Immerse the tipoff the tube ina basin of water and watch out for bubbles going out from the tube

Aspirate gastric content

Deep breath and hold it, this will close the glottis preventing aspiration of gastric content

Instruct the client to perform valsalva maneuver while pulling out the tube

Instruct the client to swallow while pulling out the tube

None of the above

Sitting position

Fowlers

Right side lying position

All of the above

Stop temporarily by clamping or pinching the tubing.

Do not stop feeding because it is a normal reaction

Stop the feeding and wait for the next shift to do the feeding

Flush the tube with 30cc water

Make sure that the formula instilled is not too thick

Do not instill medication especially in solid form

Raise the tip of the tube to a higher position

Instill 30-60 cc of water

Raise the tip to high level to empty the tube

Clamp the tube

Position the client in fowler’s position

Avoid giving client gas forming food

At least 30 minutes

The most is 30 minutes

The client can be in any position of comfort

It is unnecessary to let the client wait because it is against the patient’s right

Discard

Return to the client

Both a and b

None of the above

Auscultate after insertion to check if the tube is in the right place

Attach to mechanical ventilation machine

Suction secretions

Humidify air

Suction the tube every 2 hours

Humidify the air

Cleanse the tube with PNSS and Hydrogen Peroxide

All of the above

Perform oral care ( tooth brush, swabs and antiseptic mouthwash or hydrogen peroxide diluted with water)

Perform oral suctioning

There is no need to suction the mouth since the nurse is already suctioning the tracheostomy tube

None is an exception

Allay the client’s fear and anxiety by staying with the client

The nurse should prepare spare tracheostomy tubes that include same size and 1/2 size smaller

Be alert to complications including obstruction, hemorrhage, subcutaneous emphysema, tube dislodgement, periostomal irritation, redness, or breakdown.

None of the above

Let the child hyperextend the neck

Use the most restrictive immobilizing methods when positioning the child

Placement of rolled towel or diaper under the child’s shoulders and neck

Avoid the sniffing position

Prevent potential aspiration by maintaining environment free of safety hazards.

Routine tracheostomy site care and dressing change should be done at least once a shift or any time the site or dressing becomes wet or soiled. Do not use gauze dressing as loose filaments may be inhaled into the tracheostomy

All tracheostomy tube changes/replacements are a two person procedure.

None is an exception

From the tip of the nose to the earlobe to the midpoint of the chest

Place an appropriately sized catheter into an extra artificial airway of the same size. Verify appropriate depth for suctioning and mark suction catheter to the appropriate depth with tape.

It depends on the judgment of the nurse

It is the responsibility of the respiratory therapist to determine the length of the catheter to be inserted.

10 and 20

15 and 20

10 and 15

5 and 10

Infants and children unable to notify others of distress must be observed at all times

Initiate “Code Blue” and provide resuscitation if child experiences respiratory failure.

Maintain pulmonary toilet, e.g., cough, deep breath, incentive spirometer activity.

None is an exception.

Tracheostomy tube

Tracheostomy

Endotracheostomy

Cathetherization