c.

Recording the intake and output

d. Checking the vital signs every 15 minutes

28. A nurse has just administered an injection to a client. After the injection, the
nurse accidentally drops the syringe on the floor.Whichaction is most appropriate
in this situation?

a. Carefully pick up the syringe from the floor and gently recap the needle

b.Carefully pick up the syringe and dispose it in a sharp container

c.Obtained a dust pan and mop to sweep up the syringe

d. Call the housekeeping department to pick up the syringe

29. Saline solution is used to irrigate a nasogastric tube used for decompression
based on which rationale?

a.Irrigating with water is a contaminated procedure

b. Saline solution is a hypertonic solution

c.Saline solution replaces electrolyte loss through nasogastric suction

d. Saline solution is less irritating to the gastric mucosa

30.Client receiving hypertonic tube feedings most commonly develop diarrhea

because of:

a. Increased fiber intake b.Bacterial contamination c. Inappropriate positioning

d.High osmolarity of feeding

31. The nurse should administer a nasogastric tube feeding slowly to reduce the
hazard of:

a.Distention

b. Flatulence

c.Indigestion d.Regurgitation

32.When caring with a client with NGT attached to suction, the nurse should:

a. Irrigate the tube with normal saline

b. Use sterile technique in irrigating the tube

c. Withdraw the tube quickly when decompression is terminated

d. Allow the client to have small chips of ice or sip of water unless nauseated
33. After partial gastrectomy is performed, a client is returned to the unit with an
IV solution infusing and an NGT in place. The nurse notesthat there has been no
nasogastric drainage for 30 minutes. There is an order to imgate the NGT PRN.
The nurse should insert:

a. 30 ml of normal saline and withdraw slowly

c.50 ml of saline and increase pressure of suction

b. 20 ml of air and clamp off suction for 1 hour

d. ml of distilled water and disconnect the suction for 30 minutes

34. Carl is a male patient admitted for bums several days ago. He has been having
intermittent NGT feeding which is to be discontinued.What is the most important
criterion for the removal of the NGT?

a.Presence of abdominal distention

c.Passage of flatus

b.Absence of bowel sounds

d. Presence of gurgling sound upon introduction of air in the NGT tube

35. When an intestinal obstruction is suspected, a client has a nasogastric tube

inserted and attached to suction.Critical assessment of this

client includes observation for:

a.Edema

b.Belching c.Dehydration d.Excessive salivation

36. A client is to have a gastric gavage.When the gavage tube is being inserted,
the nurse shouid place the client in the:

a.Supine position

b.Fowler's position

c.High-Fower's position

d. Trendelenburg's position

37. After a client has an enteral feeding tube inserted, the most accurate method
for verification initial placement is

a.Abdominal x-ray

b. Auscultation

c. Flushing tube with saline

d.Aspiration for gastric contents

38. Barium salts in GI series and barium enemas serves to:

a.Fluoresce and thus illuminate the alimentary tract

b. Give off visible light and illuminates the alimentary tract

c.Dye the alimentary trct and thus provide for color-contrast

39. During the administration of an enema, a client complains of cramps. The

nurse should:

a.Give it at slower rate

c.Stop until cramps are gone

b. Discontinue the procedure

d.Lower the height of the container

40. Which action is essential when the nurse provides a continuous enteral
feeding?

a.Elevate the head of the bed

c.Warm the formula before administering it

b. Position the client on the left side

d. Hang a full day's worth of formula at one time

41.When performing a colostomy irrigation, the nurse inserts the catheter into
the stoma:

a.5cm(2 inches)

b. 10 cm (4 inches)

c.15 cm (6 inches)

d.20cm(18.inches

42.A client is to have an enema to reduce flatus. The rectal catheter should be
inserted:

a.2 inches

b. 4 inches

c.6 inches

d.8 inches

43.When receiving an enema, the client should be placed in:

a.Left side lying position b. Back-lying position

c.Knee-chest position

d.Mid-Fowler's position

44.Mr. Dantes has a fecal impaction.The nurse correctly administers an oil-

retention enema by doing which of the following?

a.Administering a large volume of solution (500 to 1,000 ml)

b. Mixing milk and molasses in equal part for an enema

c.Instructing the patient to retain the enema for at least 30 minutes

d.Following the return-flow or Harris flush procedure

45.When teaching a client to care for a new colostomy, the nurse should
recommend that the irrigation be done at the same time everyday. The time
selected should:

a.Be approximately 1 hour before breakfast

c.Approximate the client's usual daily time for elimination

b.Provide ample uninterrupted bathroom use at home d.Be about halfway

between the two largest meals of the day

46.When teaching a client with permanent colostomy what might be expected on

discharge, the nurse should discuss:

a. Need for special clothing

c.Periodic dilation of the stoma

b.Importance of limiting activities

d.Bland,low-residue diet regimen

47.A client with colostomy should follow diet that is:

a.Rich in protein

b.Low in fiber content

c.High in carbohydrate

d. As close to normal as possible

48.The solution of choice used to maintain patency of a nasointestinal tube is:

a.Purified water

b.Hypotonic saline
c. Isotonic saline

d. Hypertonic glucose

49.If,during colostomy irrigation, a client complains of abdominal cramps, the

nurse should:

a.discontinue the irrigation

c.clamp the catheter for few minutes

b.lower the container of fluid

d. advance.the catheter about 2.5 cm(1 inch)

50.When suctioning a client with a tracheostomy the nurse must remember to:

a.Use a sterile catheter with each insertion

c.Insert the catheter until the cough reflex is stimulated

b.Initiate suction as the catheter is being withdrawn d.Remove the inner cannula
befre inserting the suction catheter