NR 325Fundamental CMS exam 2020 Chamberlain College of Nursing
Fundamental CMS Exam 2020
Gastrointestinal Therapeutic Procedures:
Nasogastric Tube: Preparation
o DON clean gloves
o VERIFY patient using two identifiers
o LISTEN to bowel and breath sounds
o Rip 3 pieces of tape, plus one piece torn halfway down the center
o SIT THE PATIENT UP in High Fowler’s position
o If hooking up to suction, verify that the suction equipment works
o Have the tissues and emesis basin readily available for the patient
o ALERT the patient that the procedure will be uncomfortable and may cause gagging and
o nasal discomfort.
o OBTAIN verbal consent
o LOOK in the back of the patient’s throat and inside the nares with a penlight
o ASK the patient to swallow
NG tube placement- Clean technique
Prior to ask AND look the patient if they have nasal polyps, deviated sputum, nose bleeds, fractured nose/oral,
anticoagulant therapy.
o Gather supplies, making sure gastric decompression and lavage, are ready for suctioning or irrigation.
o Measure the distance of tube from the tip of the nose to earlobe to xiphoid process.
o Patient is in high fowlers position. Raise the bed to hip level.
o With a penlight look into the patients nose and mouth. Assess gag reflex against the uvula.
o Listen to lung and abdominal sounds
o Dip the tube 3 to 4 inches into a glass of room temperature water a water-soluble lubricant (no
petroleum jelly) the tip of the tube before inserting.
o Patient first tilts their head back, insert NG tube into you reach the posterior nasopharynx, aiming the tube
towards the ear.
o Relax and flex head/chin toward chest and start taking small sips of water
o Encourage the patient to swallow sips of water and rotate the tube and rotate the tube while inserting.
o Avoid inserting while the patient is inhaling.
,NR 325Fundamental CMS exam 2020 Chamberlain College of Nursing
o Look in the back of the patient’s throat with a pen light to see if the tube is coiled or not.
o Anchor tubing with tape, suction the end of the tubing to get gastric secretions check pH (2-4) and X-
ray ordered to know for sure.
o Flush tubing 30 ml before and after feeding.
o Auscultate the patient’s bowel and breath sounds.
o PO meds that are not extended release tablets may be crushed and pushed through a NG tube; crush meds
separately (not with feeding) into a fine powder; Mix each medication with a small amount of water;
Flush the tube before, in between, and after each med; meds may be pushed or given by gravity.
o Secure the NG tube to the client’s gown- to make sure the client doesn’t hank out and cause
nostril irritation.
o Preform frequent oral hygiene care
NG Indications
Decompression is the removal of gases or stomach contents to relieve distension, nausea, or vomiting. Tube
types: Miller-Abott, Levin, and Salem pump.
Feeding is an alternative method of oral route for administering nutritional supplements. Tube types: Dobhoff, Duo
and Levin.
Lavage is washing out the stomach or pumping out the stomach to treat active bleeding, indigestion of poison, or for
gastric dilation. Tube types: Ewald, Levin, and Salem pump.
Compression is using internal balloon to apply pressure for preventing hemorrhage. Tube types: Sengstaken-
Blakemore
NG complications
Coiled tube occurs when the tube is twisted in the throat during insertion. Fix: pull back slightly on the tube to
straighten it.
NG tube placed in the lungs, make sure to assess bowel and breath sounds. The patient should not be coughing
frequently. This is an indication that the tube is in the lungs.
Tissue, throat, and nasal trauma- The tube can injure the mucosa of the throat and irritate the nares.
Nasogastric Removal:
1. Don clean gloves
2. Remove the tape from the patient’s gown and nares
3. Ask the patient to hold their breath
4. Withdrawal the tube carefully and consistently
5. Pinch the tubing while removing (The nurse should pinch the NG tube while removing
the tube to decrease the risk of aspiration of any gastric contents)
6. Examine the tube tip for intactness and blood.
Bowel Elimination:
Positioning a bed pan-
o Elevate bed 30-35 degrees
o Press bedpan on then press down
o Make sure they are comfortable and not lying flat
,NR 325Fundamental CMS exam 2020 Chamberlain College of Nursing
Enemas: Promote defection by stimulating peristalsis to relieve constipation
o Left SIMs position
o Must lubricate the tip of the inserting tubing 2 to 3 inches; Insert 3 to 4 inches into the rectum
o 12-18 inches above a patient’s waist
o Adult & Adolescent: 3 to 4 inches into the rectum; Child: 2 to 3 inches
o Cramping is going to happen= slow the rate of the infusion (lower the bag); Ask the patient to take a
deep breath and then install a small amount of fluid.
o Obtain a pulse rate FIRST/AFTER for patients that have cardiac disease. Manipulation of the rectal
tissue can lead to sudden decline in pulse rate.
o Regular time= 5 to 10 mins except oil retention enema (30 mins)
o Hypoactive bowel sounds appear with someone right after abdominal surgery; Paralytic ileus occurs
when someone has absent bowel sounds (TPN for food and IV- right into the blood stream)
o When the patient feels they need to stop the enema and go to the bathroom- instruct that patient to hold
their enema a little bit longer.
a. Tap water (1 point)
o Is hypotonic- so should be used carefully with fluid volume overload patients because you
you will be adding more water into their cells- can cause cardiovascular collapse from
large amounts of fluid absorbed into the cells.
o Should not be repeated more than once a day.
b. Soap Suds (1 point)
o You would add soap suds to either tap water or to a saline solution. This causes
intestinal irritation that stimulates peristalsis.
o Use only pure castile soap- in a liquid form
o CAUTION this use with pregnant women and older adults as this may cause an
electrolyte imbalance or damage to their intestinal mucosa.
c. Oil retention (1 point)
o These have a lubricating effect on the feces- in the rectum and colon. The feces absorb the
oil making them much softer and easier to pass.
o An oil enema can stay in the patient for 30 minutes but preferably 1 to 3 hours-
patient retains it well.
o Used when patients are constipated and prior to fecal impaction removal- it will be less painful.
d. Normal Saline (1 point)
o Safest solution to use- same osmotic pressure as fluids found in the bodies interstitial
spaces that surround the bowel. Less of a risk to use than other enemas.
o Can be potentially given 1 to 3 times a day without the risk of a fluid electrolyte imbalance.
o Stimulating peristalsis
e. Fleet- Hypertonic Solution (1 point)- Preparation for surgery
o This solution should be used with caution- as it pulls fluids out of the interstitial spaces in
the bowel. Patients that are dehydrated, AVOID young infants or kidney issues should not
use this.
o This can be used for a patient with fluid volume excess
o Not used with patients that are hypertensive
Fundamental CMS Exam 2020
Gastrointestinal Therapeutic Procedures:
Nasogastric Tube: Preparation
o DON clean gloves
o VERIFY patient using two identifiers
o LISTEN to bowel and breath sounds
o Rip 3 pieces of tape, plus one piece torn halfway down the center
o SIT THE PATIENT UP in High Fowler’s position
o If hooking up to suction, verify that the suction equipment works
o Have the tissues and emesis basin readily available for the patient
o ALERT the patient that the procedure will be uncomfortable and may cause gagging and
o nasal discomfort.
o OBTAIN verbal consent
o LOOK in the back of the patient’s throat and inside the nares with a penlight
o ASK the patient to swallow
NG tube placement- Clean technique
Prior to ask AND look the patient if they have nasal polyps, deviated sputum, nose bleeds, fractured nose/oral,
anticoagulant therapy.
o Gather supplies, making sure gastric decompression and lavage, are ready for suctioning or irrigation.
o Measure the distance of tube from the tip of the nose to earlobe to xiphoid process.
o Patient is in high fowlers position. Raise the bed to hip level.
o With a penlight look into the patients nose and mouth. Assess gag reflex against the uvula.
o Listen to lung and abdominal sounds
o Dip the tube 3 to 4 inches into a glass of room temperature water a water-soluble lubricant (no
petroleum jelly) the tip of the tube before inserting.
o Patient first tilts their head back, insert NG tube into you reach the posterior nasopharynx, aiming the tube
towards the ear.
o Relax and flex head/chin toward chest and start taking small sips of water
o Encourage the patient to swallow sips of water and rotate the tube and rotate the tube while inserting.
o Avoid inserting while the patient is inhaling.
,NR 325Fundamental CMS exam 2020 Chamberlain College of Nursing
o Look in the back of the patient’s throat with a pen light to see if the tube is coiled or not.
o Anchor tubing with tape, suction the end of the tubing to get gastric secretions check pH (2-4) and X-
ray ordered to know for sure.
o Flush tubing 30 ml before and after feeding.
o Auscultate the patient’s bowel and breath sounds.
o PO meds that are not extended release tablets may be crushed and pushed through a NG tube; crush meds
separately (not with feeding) into a fine powder; Mix each medication with a small amount of water;
Flush the tube before, in between, and after each med; meds may be pushed or given by gravity.
o Secure the NG tube to the client’s gown- to make sure the client doesn’t hank out and cause
nostril irritation.
o Preform frequent oral hygiene care
NG Indications
Decompression is the removal of gases or stomach contents to relieve distension, nausea, or vomiting. Tube
types: Miller-Abott, Levin, and Salem pump.
Feeding is an alternative method of oral route for administering nutritional supplements. Tube types: Dobhoff, Duo
and Levin.
Lavage is washing out the stomach or pumping out the stomach to treat active bleeding, indigestion of poison, or for
gastric dilation. Tube types: Ewald, Levin, and Salem pump.
Compression is using internal balloon to apply pressure for preventing hemorrhage. Tube types: Sengstaken-
Blakemore
NG complications
Coiled tube occurs when the tube is twisted in the throat during insertion. Fix: pull back slightly on the tube to
straighten it.
NG tube placed in the lungs, make sure to assess bowel and breath sounds. The patient should not be coughing
frequently. This is an indication that the tube is in the lungs.
Tissue, throat, and nasal trauma- The tube can injure the mucosa of the throat and irritate the nares.
Nasogastric Removal:
1. Don clean gloves
2. Remove the tape from the patient’s gown and nares
3. Ask the patient to hold their breath
4. Withdrawal the tube carefully and consistently
5. Pinch the tubing while removing (The nurse should pinch the NG tube while removing
the tube to decrease the risk of aspiration of any gastric contents)
6. Examine the tube tip for intactness and blood.
Bowel Elimination:
Positioning a bed pan-
o Elevate bed 30-35 degrees
o Press bedpan on then press down
o Make sure they are comfortable and not lying flat
,NR 325Fundamental CMS exam 2020 Chamberlain College of Nursing
Enemas: Promote defection by stimulating peristalsis to relieve constipation
o Left SIMs position
o Must lubricate the tip of the inserting tubing 2 to 3 inches; Insert 3 to 4 inches into the rectum
o 12-18 inches above a patient’s waist
o Adult & Adolescent: 3 to 4 inches into the rectum; Child: 2 to 3 inches
o Cramping is going to happen= slow the rate of the infusion (lower the bag); Ask the patient to take a
deep breath and then install a small amount of fluid.
o Obtain a pulse rate FIRST/AFTER for patients that have cardiac disease. Manipulation of the rectal
tissue can lead to sudden decline in pulse rate.
o Regular time= 5 to 10 mins except oil retention enema (30 mins)
o Hypoactive bowel sounds appear with someone right after abdominal surgery; Paralytic ileus occurs
when someone has absent bowel sounds (TPN for food and IV- right into the blood stream)
o When the patient feels they need to stop the enema and go to the bathroom- instruct that patient to hold
their enema a little bit longer.
a. Tap water (1 point)
o Is hypotonic- so should be used carefully with fluid volume overload patients because you
you will be adding more water into their cells- can cause cardiovascular collapse from
large amounts of fluid absorbed into the cells.
o Should not be repeated more than once a day.
b. Soap Suds (1 point)
o You would add soap suds to either tap water or to a saline solution. This causes
intestinal irritation that stimulates peristalsis.
o Use only pure castile soap- in a liquid form
o CAUTION this use with pregnant women and older adults as this may cause an
electrolyte imbalance or damage to their intestinal mucosa.
c. Oil retention (1 point)
o These have a lubricating effect on the feces- in the rectum and colon. The feces absorb the
oil making them much softer and easier to pass.
o An oil enema can stay in the patient for 30 minutes but preferably 1 to 3 hours-
patient retains it well.
o Used when patients are constipated and prior to fecal impaction removal- it will be less painful.
d. Normal Saline (1 point)
o Safest solution to use- same osmotic pressure as fluids found in the bodies interstitial
spaces that surround the bowel. Less of a risk to use than other enemas.
o Can be potentially given 1 to 3 times a day without the risk of a fluid electrolyte imbalance.
o Stimulating peristalsis
e. Fleet- Hypertonic Solution (1 point)- Preparation for surgery
o This solution should be used with caution- as it pulls fluids out of the interstitial spaces in
the bowel. Patients that are dehydrated, AVOID young infants or kidney issues should not
use this.
o This can be used for a patient with fluid volume excess
o Not used with patients that are hypertensive
