Uhhcs Ngt, Chest And Tracheostomy (January 2019) Quiz

1. 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.

Before removing the NGT tube, the nurse would instruct the stroke client to take a long breath and hold it. This is because taking a deep breath and holding it helps to close the glottis and prevent aspiration or the entry of food or liquid into the lungs. By doing this, the client can ensure that they do not inhale any food or liquid while the tube is being removed, reducing the risk of complications.

Explanation

Before removing the NGT tube, the nurse would instruct the stroke client to take a long breath and hold it. This is because taking a deep breath and holding it helps to close the glottis and prevent aspiration or the entry of food or liquid into the lungs. By doing this, the client can ensure that they do not inhale any food or liquid while the tube is being removed, reducing the risk of complications.

2. 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.

Coughing out blood after the removal of the endotracheal tube requires immediate intervention by the physician because it could indicate a serious complication such as bleeding in the airway or lung. This symptom may suggest damage to the respiratory system or infection, and prompt medical attention is necessary to assess and manage the situation effectively. Sore throat, hoarseness of the voice, and neck discomfort are common after the removal of an endotracheal tube and may resolve on their own or with conservative measures.

Explanation

Coughing out blood after the removal of the endotracheal tube requires immediate intervention by the physician because it could indicate a serious complication such as bleeding in the airway or lung. This symptom may suggest damage to the respiratory system or infection, and prompt medical attention is necessary to assess and manage the situation effectively. Sore throat, hoarseness of the voice, and neck discomfort are common after the removal of an endotracheal tube and may resolve on their own or with conservative measures.

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

4

12

24

36

Continuous type of feedings is administered over a 24-hour period because it allows for a steady and constant supply of nutrients to be delivered to the patient. This is especially important for individuals who are unable to eat or digest food normally. By administering the feedings continuously over a 24-hour period, the patient's nutritional needs can be met without overwhelming their digestive system.

Explanation

Continuous type of feedings is administered over a 24-hour period because it allows for a steady and constant supply of nutrients to be delivered to the patient. This is especially important for individuals who are unable to eat or digest food normally. By administering the feedings continuously over a 24-hour period, the patient's nutritional needs can be met without overwhelming their digestive system.

4. 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 accurate measurement for the length of the nasogastric tube to be inserted. The xiphoid process is the bony projection at the lower end of the sternum, and this measurement ensures that the tube reaches the stomach without going too far.

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 accurate measurement for the length of the nasogastric tube to be inserted. The xiphoid process is the bony projection at the lower end of the sternum, and this measurement ensures that the tube reaches the stomach without going too far.

5. 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.

The nurse should reinstill the amount and continue with administering the feeding because a residual amount of 90ml is within an acceptable range. This indicates that the previous feeding has been adequately digested and there is no need to discard the residual or hold the due feeding. Skipping the feeding and administering the next one due in 4 hours would disrupt the feeding schedule and may not be necessary.

Explanation

The nurse should reinstill the amount and continue with administering the feeding because a residual amount of 90ml is within an acceptable range. This indicates that the previous feeding has been adequately digested and there is no need to discard the residual or hold the due feeding. Skipping the feeding and administering the next one due in 4 hours would disrupt the feeding schedule and may not be necessary.

6. 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.

The endotracheal tube should be placed 1-2 cm above the carina during a chest x-ray. This is important to ensure proper placement and function of the tube. Placing the tube too high or too low can lead to complications such as inadequate ventilation or damage to the lungs. Therefore, it is crucial to position the tube within this specific range for optimal patient care.

Explanation

The endotracheal tube should be placed 1-2 cm above the carina during a chest x-ray. This is important to ensure proper placement and function of the tube. Placing the tube too high or too low can lead to complications such as inadequate ventilation or damage to the lungs. Therefore, it is crucial to position the tube within this specific range for optimal patient care.

7. 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.

The nurse checks the nasogastric tube position by aspirating the stomach contents and checking the pH level. A pH level of 5.5 indicates correct tube placement. This is because the stomach is typically acidic, with a pH range of 1.5-3.5. A pH level of 5.5 suggests that the tube is in the stomach, as it is within the expected acidic range. Higher pH levels would indicate that the tube is not in the stomach but may be in the esophagus or respiratory tract. Therefore, a pH level of 5.5 is the correct tube placement.

Explanation

The nurse checks the nasogastric tube position by aspirating the stomach contents and checking the pH level. A pH level of 5.5 indicates correct tube placement. This is because the stomach is typically acidic, with a pH range of 1.5-3.5. A pH level of 5.5 suggests that the tube is in the stomach, as it is within the expected acidic range. Higher pH levels would indicate that the tube is not in the stomach but may be in the esophagus or respiratory tract. Therefore, a pH level of 5.5 is the correct tube placement.

8. The nurse is handling a client with a chest tube. Suddenly, the chest drainage system is accidentally disconnected, what is the most appropriate action for the nurse to take?

Secure the chest tube using a tape.

Clamp the chest tube immediately.

Place the end of the chest tube in a container of normal sterile saline.

Apply an occlusive dressing and notify the physician.

If the chest drainage system is accidentally disconnected, the most appropriate action for the nurse to take is to place the end of the chest tube in a container of normal sterile saline. This will help to maintain the sterility of the chest tube and prevent air from entering the pleural space. It will also allow for the drainage of any fluid that may accumulate in the chest tube. Securing the chest tube with tape may not be sufficient to prevent air from entering the pleural space, clamping the chest tube immediately can lead to a tension pneumothorax, and applying an occlusive dressing and notifying the physician may not be necessary unless there are other complications.

Explanation

If the chest drainage system is accidentally disconnected, the most appropriate action for the nurse to take is to place the end of the chest tube in a container of normal sterile saline. This will help to maintain the sterility of the chest tube and prevent air from entering the pleural space. It will also allow for the drainage of any fluid that may accumulate in the chest tube. Securing the chest tube with tape may not be sufficient to prevent air from entering the pleural space, clamping the chest tube immediately can lead to a tension pneumothorax, and applying an occlusive dressing and notifying the physician may not be necessary unless there are other complications.

9. A nurse is checking a family member who is performing tracheostomy care for a client. Which of the following actions by the family member should the nurse intervene?

Removing the inner cannula and cleaning using universal precaution.

Suctioning the tracheostomy tube before performing tracheostomy care.

Changing the old tracheotomy ties and securing the tube in place.

Replacing the inner cannula and cleaning the site of the stoma.

The nurse should intervene when the family member removes the inner cannula and cleans using universal precautions. This is because the inner cannula should only be removed and cleaned by a healthcare professional to prevent accidental dislodgment or damage to the tracheostomy tube. The family member can perform other actions such as suctioning the tracheostomy tube, changing the tracheotomy ties, and cleaning the site of the stoma, which are within their scope of practice and can help maintain the client's airway and prevent infection.

Explanation

The nurse should intervene when the family member removes the inner cannula and cleans using universal precautions. This is because the inner cannula should only be removed and cleaned by a healthcare professional to prevent accidental dislodgment or damage to the tracheostomy tube. The family member can perform other actions such as suctioning the tracheostomy tube, changing the tracheotomy ties, and cleaning the site of the stoma, which are within their scope of practice and can help maintain the client's airway and prevent infection.

10. While changing the tapes on a tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action?

Call a respiratory therapist to reinsert the tracheotomy.

Cover the tracheostomy site with a sterile dressing.

Call the physician to reinsert the tracheotomy.

Grasp the retention sutures to spread the opening.

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Explanation

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11. 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.

The given statement is true because the Levin tube is a nasogastric tube with two lumens, one for suctioning and the other for instilling fluids or medications. It also has an air vent to prevent the build-up of pressure. The other options, Cantor tube, Miller-Abbott tube, and Sengstaken-Blakemore tube, are all described accurately in terms of their characteristics.

Explanation

The given statement is true because the Levin tube is a nasogastric tube with two lumens, one for suctioning and the other for instilling fluids or medications. It also has an air vent to prevent the build-up of pressure. The other options, Cantor tube, Miller-Abbott tube, and Sengstaken-Blakemore tube, are all described accurately in terms of their characteristics.

12. The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate of the nurse?

Increase the suction pressure so that the bubbling becomes vigorous.

Do nothing since this is an expected finding.

Immediately clamp the chest tube and notify the physician.

Check for an air leak because the bubbling should be intermittent.

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Explanation

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13. The nurse is assessing the functioning of a chest tube drainage system in a client with hemothorax. Which of the following findings should prompt the nurse to notify the physician?

Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation.

Drainage system maintained below the client’s chest.

Drainage amount of 100ml in the drainage collection chamber.

Occlusive dressing in place over the chest tube insertion site.

The nurse should notify the physician if there is a drainage amount of 100ml in the drainage collection chamber. This could indicate active bleeding or a significant increase in drainage, which may require further intervention or evaluation by the physician. Monitoring the drainage amount is important in assessing the client's condition and response to treatment. The fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is an expected finding and indicates proper functioning of the chest tube. The drainage system being maintained below the client's chest and the presence of an occlusive dressing over the chest tube insertion site are also appropriate and expected.

Explanation

The nurse should notify the physician if there is a drainage amount of 100ml in the drainage collection chamber. This could indicate active bleeding or a significant increase in drainage, which may require further intervention or evaluation by the physician. Monitoring the drainage amount is important in assessing the client's condition and response to treatment. The fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is an expected finding and indicates proper functioning of the chest tube. The drainage system being maintained below the client's chest and the presence of an occlusive dressing over the chest tube insertion site are also appropriate and expected.

14. 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.

Elevating the head of the bed to 45 degrees and maintaining it for 30 minutes after instillation of feeding is an inappropriate practice by the nurse. This action is not necessary for a comatose client receiving bolus enteral feedings via a nasogastric tube. It may increase the risk of aspiration and discomfort for the client. The correct position for a comatose client during and after enteral feedings is to keep the head of the bed elevated at 30 degrees to prevent aspiration.

Explanation

Elevating the head of the bed to 45 degrees and maintaining it for 30 minutes after instillation of feeding is an inappropriate practice by the nurse. This action is not necessary for a comatose client receiving bolus enteral feedings via a nasogastric tube. It may increase the risk of aspiration and discomfort for the client. The correct position for a comatose client during and after enteral feedings is to keep the head of the bed elevated at 30 degrees to prevent aspiration.

15. 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.

The most likely cause of the client being able to make verbal sounds while having an endotracheal tube is that there is a leak. A leak in the endotracheal tube can allow air to escape, allowing the client to produce verbal sounds. This finding is not normal and may indicate a problem with the placement or integrity of the tube. It is important for the nurse to address this issue promptly to ensure proper ventilation and prevent complications.

Explanation

The most likely cause of the client being able to make verbal sounds while having an endotracheal tube is that there is a leak. A leak in the endotracheal tube can allow air to escape, allowing the client to produce verbal sounds. This finding is not normal and may indicate a problem with the placement or integrity of the tube. It is important for the nurse to address this issue promptly to ensure proper ventilation and prevent complications.