NCLEX FUNDAMENTALS: SKILLS/PROCEDURES EXAM QUESTIONS WITH COMPLETE SOLUTIONS

NCLEX FUNDAMENTALS: SKILLS/PROCEDURES EXAM QUESTIONS WITH COMPLETE SOLUTIONS A client with a nasogastric tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks. Which of the following actions by the nurse are appropriate? 1) Flush the NG tube before and after the feeding 2) Place the patient in semi fowlers 3) Start the feeding after obtaining gastric residual volume of 75 mL what should gastric pH be? Gastric pH should be less than 5 The nurse is performing open endotracheal suctioning for a client with a tracheostomy tube. Which of the following actions by the nurse are appropriate? Administers 100% O2 prior to suctioning Applies suction while withdrawing the catheter from the airway Uses sterile gloves and technique throughout the procedure How long should the nurse limit each suction pass? 10 seconds The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial postprocedure monitoring plan should include what? - Level of alertness - O2 sat - Lung sounds - Respiratory pattern - Temperature is NOT included in this because s/s of infection do not occur until days later A nurse is caring for a client who has a chest tube drainage system in place. Where would the nurse observe to assess for tidaling? Water seal chamber - The water level in the water seal chamber rises and falls with inspiration and expiration, a process known as tidaling which means the connection is working properly. Suction control chamber facts This is the suction control chamber, which is usually set at -20 cm H2O to maintain negative pressure in the system. Bubbling will occur when suction is applied. Air leak gauge facts The air leak gauge (part of the water seal chamber) allows for assessment of air leaks. Continuous bubbling indicates an air leak in the system. The nurse is caring for a client with newly prescribed hearing aids. Which of the following actions by the client indicate proper use and care of hearing aids? Turns TV down when talking to the nurse Lowers TV volume completely down when inserting the aid into the ear Verifies that the battery compartment is closed before insertion Remove battery at night when not in use to extend battery life How are hearing aids cleaned? Clean hearing aids with a soft cloth The nurse is preparing to suction secretions from the airway of an unconscious client whose lungs are mechanically ventilated with an endotracheal tube. Place the steps for suctioning the endotracheal tube in the correct order. 1) Perform hand hygiene and don clean gloves. 2) Suction the oropharynx and perform oral care. 3) Hyper-oxygenate lungs at 100% O2 4) Advance catheter into trachea 5) Gently rotate catheter while suctioning 6) Evaluate patient tolerance and document The nurse is suctioning the artificial airway of a conscious client. Which actionsNCLEX FUNDAMENTALS: SKILLS/PROCEDURES EXAM QUESTIONS WITH COMPLETE SOLUTIONS A client with a nasogastric tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks. Which of the following actions by the nurse are appropriate? 1) Flush the NG tube before and after the feeding 2) Place the patient in semi fowlers 3) Start the feeding after obtaining gastric residual volume of 75 mL what should gastric pH be? Gastric pH should be less than 5 The nurse is performing open endotracheal suctioning for a client with a tracheostomy tube. Which of the following actions by the nurse are appropriate? Administers 100% O2 prior to suctioning Applies suction while withdrawing the catheter from the airway Uses sterile gloves and technique throughout the procedure How long should the nurse limit each suction pass? 10 seconds The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial postprocedure monitoring plan should include what? - Level of alertness - O2 sat - Lung sounds - Respiratory pattern - Temperature is NOT included in this because s/s of infection do not occur until days later A nurse is caring for a client who has a chest tube drainage system in place. Where would the nurse observe to assess for tidaling? Water seal chamber - The water level in the water seal chamber rises and falls with inspiration and expiration, a process known as tidaling which means the connection is working properly. Suction control chamber facts This is the suction control chamber, which is usually set at -20 cm H2O to maintain negative pressure in the system. Bubbling will occur when suction is applied. Air leak gauge facts The air leak gauge (part of the water seal chamber) allows for assessment of air leaks. Continuous bubbling indicates an air leak in the system. The nurse is caring for a client with newly prescribed hearing aids. Which of the following actions by the client indicate proper use and care of hearing aids? Turns TV down when talking to the nurse Lowers TV volume completely down when inserting the aid into the ear Verifies that the battery compartment is closed before insertion Remove battery at night when not in use to extend battery life How are hearing aids cleaned? Clean hearing aids with a soft cloth The nurse is preparing to suction secretions from the airway of an unconscious client whose lungs are mechanically ventilated with an endotracheal tube. Place the steps for suctioning the endotracheal tube in the correct order. 1) Perform hand hygiene and don clean gloves. 2) Suction the oropharynx and perform oral care. 3) Hyper-oxygenate lungs at 100% O2 4) Advance catheter into trachea 5) Gently rotate catheter while suctioning 6) Evaluate patient tolerance and document The nurse is suctioning the artificial airway of a conscious client. Which actions