Psychomotor Exam 3

What is the primary indication for using an NG tube?

To receive nutrition through tube feeding using the stomach as a natural reservoir for food.

What is one purpose of an NG tube in gastrointestinal care?

To decompress or drain unwanted fluid and air from the stomach.

What should be assessed prior to inserting an NG tube?

Patency of the patient's nares, bowel sounds, and abdominal distention.

What position should a patient be in for NG tube insertion?

Fowler to high-Fowler position.

What is the most reliable method to verify the placement of an NG tube?

X-ray.

What pH level indicates gastric contents?

Gastric contents are acidic with a pH < 5.5.

What should be documented after NG tube insertion?

Size and type of NG tube, location, measurement of exposed tube, and client's response.

What is the purpose of a Salem Sump tube?

To attach to intermittent suction and prevent gastric contents from leaking.

What are the types of feeding tubes based on duration?

Short term and long term.

What should enteral feeding orders contain?

Formula, feeding schedule or rate, water flush volume and frequency, and residual check.

What is the recommended head of bed (HOB) elevation for enteral feeding?

30-45 degrees.

What nursing action should be taken for a clogged feeding tube?

Flush the tube with 30-60 mL of water after use or every 4 hours.

What should be done if a patient experiences nausea and vomiting during tube feeding?

Ensure HOB is elevated, administer antiemetic as ordered, and hold tube feeding.

What is the nursing action for gastric residual > 200 mL?

Assessment and notifying the provider to determine if feedings should be held.

What is the protocol for administering medications via enteral feeding?

Pause tube feeding, check placement, flush tube, and administer one medication at a time.

What is the purpose of measuring residual volume in enteral feeding?

To ensure safe and effective feeding and monitor for potential complications.

What should be done if a patient has 3 or more diarrhea episodes in 24 hours?

Notify the provider and consider modifying the formula or rate.

What is the first step in IV insertion preparation?

Educate the client about the procedure.

What supplies are typically needed for peripheral IV insertion?

IV catheters, gloves, tourniquet, antiseptic swab, gauze, and saline syringe.

What is the maximum number of attempts allowed for IV insertion?

No more than 2 attempts.

What is the importance of maintaining sterility during IV insertion?

To prevent infection and ensure patient safety.

What is the rationale for monitoring blood glucose during enteral feeding?

To ensure proper metabolic response and adjust feeding as necessary.

What should be done if a patient is experiencing signs of aspiration?

Monitor respiratory status and comfort level, and hold feeding if necessary.

What is the purpose of rotating the bumper on a G-tube or J-tube?

To prevent skin irritation and ensure proper site care.

What should be done if the abdominal girth is distended?

Consider measuring abdominal girth at the umbilicus to establish a baseline.

What is the significance of the pH of intestinal fluid?

Intestinal fluid has a pH of 7 or higher, indicating its location.

What is the purpose of documenting irrigation and drainage for a Salem Sump tube?

To track the effectiveness of the tube and ensure proper care.

Where should IV insertion be performed on adults?

Hand or inner arm, preferably the nondominant arm.

What site is recommended for IV insertion in babies?

Scalp or feet.

What should be avoided when selecting an IV insertion site?

Same side as mastectomy, extremities with vascular dialysis fistulas, infection, infiltration, burn injury, antecubital area, and inside of wrist.

What is the first step in IV insertion?

Clean the skin.

What angle should the needle be inserted during IV catheter advancement?

10-15 degree angle with the bevel up.

What should be done after inserting the catheter?

Remove the tourniquet and stabilize the catheter.

What documentation is required after IV insertion?

Date and time of insertion, size of catheter, location and condition of the IV site, number of attempts, client tolerance, and pertinent teaching.

What are signs of IV infiltration?

Skin around IV is edematous or cool to touch, indicating fluid leakage into tissues.

What is phlebitis?

Inflammation of a vein characterized by redness, swelling, heat, and pain at the site.

What should be done if blood return is pulsating during IV access?

Remove the catheter, hold pressure at the site, and notify the healthcare provider.

What is the purpose of a saline lock?

To maintain venous access for medication administration without continuous fluid infusion.

What is the formula for calculating drops per minute (gtt/min)?

Volume (mL) / Time (minutes) × Drop Factor (gtt/mL) = Flow Rate (gtt/min).

What should be monitored during IV maintenance?

IV securement, redness, swelling, client report of pain, infusion rate, and tubing expiration.

What is the maximum time an IV site can remain in place?

Typically every 72-96 hours, or sooner if complications arise.

What is the purpose of a PCA (Patient Controlled Analgesia) pump?

To allow clients to self-administer analgesics within safety limits.

What should be done if a cloudy white substance forms in the IV tubing?

Check for incompatibility of the medications or solutions.

What is the recommended action if a client shows signs of fluid overload?

Monitor vital signs, place the client on their left side in Trendelenburg position, and call for assistance.

What is the significance of the lockout interval in PCA?

It prevents overdose by limiting the frequency of self-administration.

What should be done before administering IV push medications?

Assess the IV site, clean the port, and check for blood return.

What is the purpose of backpriming in secondary infusions?

To allow the primary IV solution to flow into the secondary tubing before administering the medication.

What documentation is required for IV therapy?

Date and time of administration, type and volume of solution, rate of solution, assessment of IV site, and any complications.

What should be done if the IV pump beeps 'air in line'?

Check the tubing for air bubbles and ensure connections are secure.

What is the first step in discontinuing an IV catheter?

Remove tape around the site and place a gauze over the insertion site.

What is the appropriate pressure duration after IV catheter removal?

2-3 minutes for general clients, 5-10 minutes for clients on anticoagulant therapy.

What should be done if a client reports pain at the IV site?

Assess the site for complications and notify the healthcare provider if necessary.

What is the purpose of using a mini-infuser?

To administer a drug mixed with a small amount of IV solution over a short period at prescribed intervals.

What should be done if a 'blown vein' occurs?

Remove the IV, apply pressure, and assess for any further complications.

What is the primary indication for enteral feeding tubes?

Used when the GI tract is functioning but the patient cannot eat normally.

Name two common indications for enteral tubes.

Provide nutrition and medications; decompress stomach.

What are the short-term enteral feeding tube types?

NG (Nasogastric) and NI (Nasointestinal/nasojejunal).

What are the long-term enteral feeding tube types?

PEG tube (Percutaneous Endoscopic Gastrostomy), G tube, and J tube.

What position should a patient be in for safe nasogastric tube insertion?

High Fowler's position.

What is the most reliable method for verifying NG tube placement?

X-ray.

What is the expected pH of gastric contents?

Less than 5.5; if on acid inhibitors, 4-6.

What should be documented for an NG tube?

Tube size and type, location, external measurement, client response, and confirmation method.

What is the preferred method of enteral feeding?

Bolus feeding delivered by large syringe via gravity.

What is the intervention for high residual volume in enteral feeding?

Stop feeding, reassess in 1 hour, and notify provider if still high.

What are the indications for IV therapy?

Fluid replacement, electrolytes, medications, blood products, and when the patient cannot take PO.

What are preferred sites for IV insertion?

Hand, forearm, nondominant arm, and distal sites first.

What is the maximum time a tourniquet should be applied during IV insertion?

No longer than 2 minutes.

What are signs of infiltration during IV therapy?

Cool skin, swelling, and edema.

What is the intervention for phlebitis?

Remove IV and restart at a new site.

What should be done when discontinuing an IV?

Remove dressing, place gauze over site, remove catheter, and apply pressure.

What is the formula for IV pump programming?

Rate = Volume ÷ Time.

What is the formula for calculating gravity flow rate?

Volume ÷ Time × Drop Factor.

What are the signs of fluid overload in IV therapy?

Crackles, dyspnea, edema, and increased BP.

What is the safety feature of PCA (Patient Controlled Analgesia)?

Lockout interval to prevent overdose.

What position should a patient be placed in for an air embolism?

Left side Trendelenburg.

What is the expected action if a patient experiences nausea during enteral feeding?

Elevate HOB, hold feeding, check residual, and notify provider.

What should be done when administering medication through a feeding tube?

Pause feeding, check residual and placement, administer one medication at a time, and flush between medications.

What is the intervention for diarrhea occurring 3 or more times in 24 hours during enteral feeding?

Notify provider, adjust formula/rate, and provide skin care.

What is the angle for IV catheter insertion?

10-15 degrees.

What should be monitored during PCA therapy?

Respiratory rate, SpO₂, level of consciousness, pain level, and capnography.

What is the expected action for a clogged feeding tube?

Flush 30-60 mL water every 4 hours.