Test Bank For Concept-Based Clinical Nursing Skills
Fundamental to Advanced 1st Edition By Loren Nell Melton
Stein, Connie J Hollen 9780323625579 ALL Chapters .
Fluid from a tube properly placed in the stomach should test at a pH of ___ or lower - ANSWER: 5
Anything higher means that the tube MUST be replaced
To determine where to mark the correct length on an NG tube for a 2-month-old infant, how should
the nurse measure? - ANSWER: From nose to earlobe, then from earlobe to midpoint between
xiphoid process and umbilicus
During a teaching session, the nurse informs the child's family that placement of a postpyloric tube is
most reliably confirmed by which method? - ANSWER: A radiograph of the abdomen
The nurse is attempting to insert an NG tube into a 13-year-old child with no cervical injuries. To
facilitate passage of the NG tube with minimal trauma, what should the nurse do? - ANSWER: flex the
child's head forward
When educating the family of a child with an NG tube, how should the nurse describe the purpose of
a gastric decompression tube? - ANSWER: it ensures that the child's stomach remains empty
During assessment of a child with an orogastric tube for gastric decompression in place, the nurse
observes dry and irritated oral mucous membranes. How should the nurse proceed? - ANSWER:
provide more frequent oral care
An incentive spirometer after surgery is normally used for? - ANSWER: it prevents post-operative
complications
A 6-month-old infant has an NG tube in place after surgery. The infant no longer needs the tube.
Before removing the tube, what must the nurse do? - ANSWER: Occlude the tube by bending it
(this is so that no secretions from the stomach end up in the lungs)
The nurse is assessing a 9-month-old infant who is receiving enteral nutrition through an NG tube.
During assessment, the infant coughs and vomits a small amount of thick fluid. What should the nurse
do next? - ANSWER: Suction the oropharynx
Which statement demonstrates the patient's ability to perform incentive spirometry correctly? -
ANSWER: The patient inhales slowly and deeply from a normal expiratory breath.
What is the minimum acceptable postoperative volume to be achieved with an incentive spirometer?
- ANSWER: 2000ml
A patient with COPD is recovering from postoperative abdominal surgery. The prescribing practitioner
has ordered an incentive spirometer to decrease the chance of pneumonia. Which outcome is an
unexpected outcome? - ANSWER: Shortness of breath after the use of the incentive spirometer
what position should you place a patient when caring for Gastrostomy Tube, Jejunostomy Tube, and
Gastrojejunostomy Tubes - ANSWER: semi-fowler position with knee's bent
this helps relax the abdominal muscles
when should you flush the extension tubing of a Gastrostomy Tube, Jejunostomy Tube, or
Gastrojejunostomy Tube? - ANSWER: before and after formula and medication adminsteration
, How should you flush a gastrostomy tube? - ANSWER: flush with the lowest volume of water
necessary.
typically 2-5 milliliters for children and 1 milliliter or less for neonates
How should you flush a GJT? - ANSWER: flush the jejuno port every 4 hours with the lowest volume
needed to clear the tube
and flush the gastric port after use
You should vent a gastric port when ________ or as needed - ANSWER: ordered
What does granulation tissue formation around the GT stoma site indicate? - ANSWER: Excess tissue
has no sensation. (this is a normal occurrence)
A child has a GT in place. During daily care, leakage of stomach contents is observed around the GT;
however, the child is tolerating the procedure and does not appear to be in pain. What might the
leakage indicate? - ANSWER: balloon deflation
A nurse is giving the family of a child with a new GT discharge instructions. Which statement by the
family indicates that they understand the purpose of flushing the GT before and after medication
administration? - ANSWER: "flushing prevents clogging"
A child is admitted to the pediatric inpatient unit following a GT placement. The mother asks what the
best way is to cleanse the tube site. What should the nurse use to cleanse the site? - ANSWER: Soap
and water
For endotracheal tube closed suctioning:
Do not exceed ____ seconds per suctioning pass for an infant or ____ seconds for a child. - ANSWER:
5, 10
What should you do FIRST before starting endotracheal tube closed suctioning - ANSWER: assess
breath sounds!
Suggested negative pressure settings for endotracheal tube closed suctioning for infants and children
are - ANSWER: -60ml to -100ml mercury
You should assess _______ _______ after removing the catheter in an endotracheal tube (ET) -
ANSWER: breath sounds
Before performing closed suctioning on a 3-day-old infant, the nurse explains the procedure to the
family members. Which benefit of closed suctioning should the nurse include in the explanation? -
ANSWER: Reduced risk of infection for the child and staff members
A newly admitted child has a brain injury from a motor vehicle collision and is intubated. A new
resident in the pediatric intensive care unit writes a standing order for ET tube suctioning every 2
hours. Why is this order inappropriate? - ANSWER: The frequency of suctioning should be based on
individual need.
The nurse is preparing to suction a child with an ET tube. The family asks if normal saline should be
instilled into the ET tube as advised by a family member, who is a retired nurse. Which response is
appropriate? - ANSWER: "Instilling normal saline solution is no longer recommended."
Fundamental to Advanced 1st Edition By Loren Nell Melton
Stein, Connie J Hollen 9780323625579 ALL Chapters .
Fluid from a tube properly placed in the stomach should test at a pH of ___ or lower - ANSWER: 5
Anything higher means that the tube MUST be replaced
To determine where to mark the correct length on an NG tube for a 2-month-old infant, how should
the nurse measure? - ANSWER: From nose to earlobe, then from earlobe to midpoint between
xiphoid process and umbilicus
During a teaching session, the nurse informs the child's family that placement of a postpyloric tube is
most reliably confirmed by which method? - ANSWER: A radiograph of the abdomen
The nurse is attempting to insert an NG tube into a 13-year-old child with no cervical injuries. To
facilitate passage of the NG tube with minimal trauma, what should the nurse do? - ANSWER: flex the
child's head forward
When educating the family of a child with an NG tube, how should the nurse describe the purpose of
a gastric decompression tube? - ANSWER: it ensures that the child's stomach remains empty
During assessment of a child with an orogastric tube for gastric decompression in place, the nurse
observes dry and irritated oral mucous membranes. How should the nurse proceed? - ANSWER:
provide more frequent oral care
An incentive spirometer after surgery is normally used for? - ANSWER: it prevents post-operative
complications
A 6-month-old infant has an NG tube in place after surgery. The infant no longer needs the tube.
Before removing the tube, what must the nurse do? - ANSWER: Occlude the tube by bending it
(this is so that no secretions from the stomach end up in the lungs)
The nurse is assessing a 9-month-old infant who is receiving enteral nutrition through an NG tube.
During assessment, the infant coughs and vomits a small amount of thick fluid. What should the nurse
do next? - ANSWER: Suction the oropharynx
Which statement demonstrates the patient's ability to perform incentive spirometry correctly? -
ANSWER: The patient inhales slowly and deeply from a normal expiratory breath.
What is the minimum acceptable postoperative volume to be achieved with an incentive spirometer?
- ANSWER: 2000ml
A patient with COPD is recovering from postoperative abdominal surgery. The prescribing practitioner
has ordered an incentive spirometer to decrease the chance of pneumonia. Which outcome is an
unexpected outcome? - ANSWER: Shortness of breath after the use of the incentive spirometer
what position should you place a patient when caring for Gastrostomy Tube, Jejunostomy Tube, and
Gastrojejunostomy Tubes - ANSWER: semi-fowler position with knee's bent
this helps relax the abdominal muscles
when should you flush the extension tubing of a Gastrostomy Tube, Jejunostomy Tube, or
Gastrojejunostomy Tube? - ANSWER: before and after formula and medication adminsteration
, How should you flush a gastrostomy tube? - ANSWER: flush with the lowest volume of water
necessary.
typically 2-5 milliliters for children and 1 milliliter or less for neonates
How should you flush a GJT? - ANSWER: flush the jejuno port every 4 hours with the lowest volume
needed to clear the tube
and flush the gastric port after use
You should vent a gastric port when ________ or as needed - ANSWER: ordered
What does granulation tissue formation around the GT stoma site indicate? - ANSWER: Excess tissue
has no sensation. (this is a normal occurrence)
A child has a GT in place. During daily care, leakage of stomach contents is observed around the GT;
however, the child is tolerating the procedure and does not appear to be in pain. What might the
leakage indicate? - ANSWER: balloon deflation
A nurse is giving the family of a child with a new GT discharge instructions. Which statement by the
family indicates that they understand the purpose of flushing the GT before and after medication
administration? - ANSWER: "flushing prevents clogging"
A child is admitted to the pediatric inpatient unit following a GT placement. The mother asks what the
best way is to cleanse the tube site. What should the nurse use to cleanse the site? - ANSWER: Soap
and water
For endotracheal tube closed suctioning:
Do not exceed ____ seconds per suctioning pass for an infant or ____ seconds for a child. - ANSWER:
5, 10
What should you do FIRST before starting endotracheal tube closed suctioning - ANSWER: assess
breath sounds!
Suggested negative pressure settings for endotracheal tube closed suctioning for infants and children
are - ANSWER: -60ml to -100ml mercury
You should assess _______ _______ after removing the catheter in an endotracheal tube (ET) -
ANSWER: breath sounds
Before performing closed suctioning on a 3-day-old infant, the nurse explains the procedure to the
family members. Which benefit of closed suctioning should the nurse include in the explanation? -
ANSWER: Reduced risk of infection for the child and staff members
A newly admitted child has a brain injury from a motor vehicle collision and is intubated. A new
resident in the pediatric intensive care unit writes a standing order for ET tube suctioning every 2
hours. Why is this order inappropriate? - ANSWER: The frequency of suctioning should be based on
individual need.
The nurse is preparing to suction a child with an ET tube. The family asks if normal saline should be
instilled into the ET tube as advised by a family member, who is a retired nurse. Which response is
appropriate? - ANSWER: "Instilling normal saline solution is no longer recommended."
