Nokea
Before inserting a nasogastric tube what measurement should the nurse take?
- A. Tip of the nose to the earlobe to the xiphoid process
- B. Bridge of the nose to the xiphoid process
- C. Nose to the top of the ear to the stomach
- D. Clavicular notch to the stomach
Correct Answer: A
Rationale: The measurement is from the tip of the nose to the ear lobe to the xiphoid process.
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During insertion of a Foley catheter the patient grimaces as the balloon is inflated. What is the immediate reaction of the nurse?
- A. Withdraw the catheter.
- B. Ask the patient to bear down.
- C. Continue to inflate the balloon.
- D. Advance the catheter into the bladder.
Correct Answer: D
Rationale: Grimacing is a sign of pain indicating that the balloon might be in the urethra instead of the bladder. The catheter should be advanced before inflation.
After a Foley catheter has been removed the nurse should assess the patient for:
- A. hemorrhage.
- B. constipation.
- C. urinary retention.
- D. bladder spasm.
Correct Answer: C
Rationale: While an indwelling urinary catheter is in place, the bladder loses tone and can retain urine after the removal of the catheter.
A ____ is the diversion of urine away from a diseased or defective bladder through a surgically created opening or stoma in the skin.
Correct Answer: urostomy
Rationale: A urostomy is the diversion of urine away from a diseased or defective bladder through a surgically created opening or stoma in the skin.
What would be the correct explanation of catheter care?
- A. Cleansing the first 2 in of the catheter with soap and water every shift
- B. Disinfecting the entire catheter with alcohol every shift
- C. Lubricating the catheter with antiseptic lotion every 24 hours
- D. Cleansing the meatal-catheter junction every 24 hours
Correct Answer: A
Rationale: The first 2 in of the catheter should be cleaned with soap and water every shift or more often if the patient is incontinent. Alcohol and lotions are contraindicated. Catheter care should be done every shift.
The nurse administers an enema to a patient as ordered. What should be documented?
- A. Date
- B. Time
- C. Type and volume of enema
- D. Temperature of solution
- E. Characteristics of results
- F. How patient tolerates procedure
Correct Answer: A,B,C,D,E,F
Rationale: Following an enema date, time, type and volume of enema, temperature of solution, characteristics of results and how patient tolerated procedure should all be documented.