Care of client with a tube NCLEX – Flashcards
Unlock all answers in this set
Unlock answersquestion
Levin tube
answer
A single lumen nasogastric tube used to remove gastric contents via intermittent suction or to provide tube feedings
question
The air vent on Salem sump tube is not to be clamped and is to be kept above the level of the stomach. If leakage occurs through the air vent, instill 30 mL of air into the air vent and irrigate the main lumen with NS
answer
A double lumen nasogastric tube with an air vent, or pigtail, used for decompression with intermittent continuous suction
question
Gently and still 30 to 50 mL of water or NS with an irrigation syringe
answer
Perform irrigation every four hours to assess and maintain the patency of the tube
question
In a bolus feeding, formula is administered over 30 to 60 minutes, Every 3 to 6 hours
answer
When removing a nasogastric tube, ask client to take a deep breath and hold; remove the tube slowly and evenly over the course of 3 to 6 seconds
question
If residual is less than 100 mL feeding if administered, large volume aspirates indicate delayed gastric emptying and place the client at risk for aspiration
answer
A cyclical feeding is administered in the daytime or nighttime for approximately 8 to 16 hours
question
Position comatose client in high Fowler's and on the right side during tube feeding. Others are to be in high Fowlers position
answer
Hold the feeding and notify the HCP if Bowel sounds are absent
question
For bolus feeding, maintain the client in a high Fowler's position for 30 minutes after the feeding
answer
Assess tube placement by aspirating gastric contents and measuring the pH, should be 3.5 or lower
question
Do Not hang more solution then required for a four hour period. Because this prevents bacterial growth
answer
Change the tube feeding container and tubing every 24 hour
question
When inserting a nasogastric tube: position client with pillows behind shoulders; measure the length of the tube from the bridge of the nose to the earlobe to the xiphoid process
answer
Check expiration date on the formula before administering
question
If resistance is met, then slowly rotate and AIM the tube downward and towards the closer ear; in the intubated or semi conscious client, flex the head toward the chest while passing the tube
answer
When the tube nears the back of the throat, first black measurement on the tube, instruct the client to swallow or drink sips of water unless contraindicated
question
Withhold the-feeding if the amount is more than 100 mL or according to agency or nutritional consult recommendations
answer
Check residual volume every four hours, before each feeding, and before giving meds
question
On a daily basis, remove the adhesive tape that is securing the tube to the nose and clean and dry the skin, assessing for excoriation, and reapply the tape
answer
If irrigation is indicated through a NG tube, use normal saline solution or check agency procedure
question
Gently flush the tube with 30-50 mL of water or normal saline with irrigation syringe after the feeding
answer
jejunostomy and gastrostomy tubes are surgically inserted, so change sterile dressing every eight hours or apply as per agency policy
question
If the client with a tube feeding vomits, stop the tube feeding and place the client in a sidelying position, suction as needed
answer
Flush continuous feedings with water every four hours
question
Types of tubes to be used for intestinal tubes are the Cantor tube, which is a single lumen; and the Miller Abbet tube, which is double lumen
answer
If NG tube is attached to suction, after giving meds clamp the tube for 30 to 60 minutes
question
The tube enters the small in testifying through the pyloric sphincter because of the weight of a small bag containing tungsten at the end
answer
Intestinal tubes are used to decompress the bowel or to remove accumulated intestinal secretions when other interventions to decompress about are not effective
question
Do not secure the tube to the face with tape until it has reached final placement, may take several hours, in the intestines
answer
When inserting an intestinal tube, position the client on the right side to facilitate passage of the weighted bag in the tube through the pylorus of the stomach and into the small intestine
question
If the tube becomes blocked, notify the HCP
answer
Assess abdomen during the procedure by monitoring drainage from the tube and abdominal girth
question
Esophageal and gastric tubes may be used to apply pressure against bleeding esophageal veins to control the bleeding when other interventions are not effective for our contraindicated
answer
To remove the tube, the tungsten is removed from the balloon portion of the tube with a syringe, the tube is removed gradually, 6 inches every hour, as prescribed by the HCP
question
...
answer
These tubes are not used in client with ulceration or necrosis of the esophagus or has had previous esophageal surgery because of the risk of rupture
question
And a gastric aspiration lumen. A NG tube also is inserted in the opposite nares to collect secretions that accumulate above the esophageal balloon
answer
SengStaken - Blakemore tube: A triple lumen gastric tube with an inflatable esophageal balloon that compresses esophageal varices, an inflatable gastric balloon that applies pressure at the cardioesophageal junction...
question
A radiograph of the upper abdomen and chest confirms placement
answer
Minnesota tube; more commonly used than and is a modified SengStaken - Blakemore tube with an additional lumen, a 4 lumen gastric tube, for aspirating esophagopharyngeal secretions
question
Keep scissors at bedside at all times; monitor for respiratory distress, if it occurs cut the tube to deflate balloons
answer
Double clamp the balloonport to prevent air leaks
question
Signs of esophageal rupture: drop in blood pressure, increased heart rate, back and upper abdominal pain.
answer
Monitor for increased bloody drainage which may indicate persistent bleeding; and monitor for signs of esophageal rupture
question
If patency cannot be established with the prescribed irrigation, immediately notify the doctor
answer
With ureteral and nephrostomy tubes: never clamp; maintain patency; irrigate only if prescribed by Dr., using strict aseptic technique; use a max of 5 mL of sterile normal saline is instilled slowly and gently
question
...
answer
monitor output closely with ureteral or nephrostomy tubes. Urine output of less than 30 mL per hour or lack of output for more than 15 minutes should be reported to the doctor immediately
question
The cuff also prevents air from passing to the vocal chords, nose, or mouth
answer
In an endotracheal tube, the cuff when inflated, produces the seal between the trachea and the cuff to prevent aspiration and ensure delivery of a set title volume
question
When inserting Foley catheter in a female, advance catheter a total of 7.5 cm, 3 inches, or until urine flows out of catheter end. When urine appears, advanced catheter another 2.5 to 5 cm, 1 to 2 inches
answer
Correct placement of endotracheal tube is 1 to 2 cm above the carina
question
...
answer
When inserting a catheter in and adult male, advance catheter 17 to 22.5 cm, 7 to 9 inches, or until urine flows out of catheter
question
With extubation, hyper oxygenated the client and suction endotracheal tube and oral cavity
answer
With an endotracheal tube, monitor cuff pressures at least every eight hours to ensure that they do not exceed 20 MM HG
question
If client is allowed to eat, sit up for meals and ensure that cuff is inflated, if tube is not capped, for meals and for one hour after meals to prevent aspiration
answer
Extubation continued: deflate the cuff, have client inhale and at peak inspiration, remove the tube, suctioning the airway through the tube while pulling it out
question
Chest tube drainage system: the drainage collection chamber is located where the chest tube from the client connects To the system
answer
Never insert a plug, or cap, into tracheostomy tube until the cuff is deflated and the inner cannula is removed; prior insertion prevents airflow to the client
question
In the waterseal chamber, Water oscillates; moves up as the clients inhales, and it moves down as the client exhales
answer
Water seal chamber: the tip of the tube is underwater, allowing fluid and air to drain from the pleural space and preventing air from entering the pleural space
question
Suction control chamber: provides the suction, which can be controlled to provide negative pressure to the chest
answer
Excessive bubbling in the waterseal chamber indicates an air leak in the chest tube system
question
...
answer
Bubbling if water in the water seal chamber may also occur in exhaling, coughing, or sneezing
question
Continuous Gentle bubbling in this chamber indicates that there is suction and does not indicate that air is escaping from the pleural space. Normal finding. Bubbling should not be intermittent
answer
The suction control chamber is filled with various levels of water to achieve the desired level of suction; without this control, lung tissue could be sucked into the chest tube
question
A knob on the collection device is used to set the prescribed amount of suction; then the wall suction source dial is turned until a small orange floater valve appears in the window on the device, indicating the correct amount of suction is applied
answer
Dry suction system in chest tube drainage system: because this is a dry suction system, absence of bubbling is noted in the suction control chamber
question
Principles of gravity and pressure and nursing care involved are the same for all types of systems and these systems allow greater ambulation and allow the client to go home with chest tubes
answer
Portable chest drainage system: small and portable; a dry system; use a control flutter valve to prevent backflow of air into clients lung
question
Mark the chest tube drainage in the collection chamber at a 1 to 4 hour intervals using a piece of tape
answer
Interventions for chest tubes: collection chamber: monitor drainage and notify Dr. if more than 70 to 100 mL per hour or if drainage becomes a bright red or increases suddenly
question
If a pneumothorax exists, intermittent bubbling in the waterseal chamber is expected as air is drained from the chest, but continuous bubbling indicates an air leak in the system
answer
Waterseal chamber: monitor for fluctuation of the fluid level. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if suction is not working properly, or if lung has reexpanded
question
Suction control chamber: gentle, not vigorous, bubbling should be noted in the section control chamber
answer
Notify Dr. if there is a continuous bubbling in the water still chamber
question
A chest x-ray assesses the position of the tube and determines whether a long have three expanded
answer
An occlusive sterile dressing is maintained at the insertion site
question
Monitor for signs of extended pneumothorax or hemothorax
answer
Assess respiratory status and auscultate lung sounds
question
Ensure that all connections are secure and encourage coughing and deep breathing
answer
Keep the drainage system below the level of the chest and the tubes free of kinks, dependent loops or other obstructions
question
If the drainage system cracks or breaks, insert the chest tube into a bottle of sterile water, remove the cracked or broken system and replace it with a new system
answer
Do not strip or milk, or clamp chest tube unless doctors order; keep a clamp and sterile occlusive dressing at bedside at all times
question
Apply a dry sterile dressing, petroleum gauze dressing, or Telfa dressing depending on doctors preference and taped in place after removal of the chest tube
answer
Upon removing the chest tube instruct the client to take a deep breath and hold it and tube is removed. If Dr. prefers, the client may be asked to take a deep breath, exhale, and bear down, Valsalva maneuver
question
...
answer
If chest tube is pulled out of the chest accidentally, pinch the skin opening together, apply an occlusive sterile dressing, cover the dressing with overlapping pieces of 2 inch tape, and call the HCP immediately
question
food particles are seen in tracheal secretions; client does not receive the set title volume on the ventilator
answer
Symptoms of tracheomalacia: increased amount of air required in the cuff to maintain seal; a larger tracheostomy tube required to prevent air leak at the stoma;
question
Management: tracheal dilation or surgical intervention
answer
Manifestations of tracheal stenosis: usually seen after the cuff is deflated or the tracheostomy tube is removed; client has increased coughing, inability to expectorate secretions, or difficulty breathing and talking
question
Manifestations: food particles seen in Trach secretions, increase air in cuff is needed to achieve a seal, increased coughing and choking while eating, client does not receive set title volume on the ventilator
answer
Tracheoesophageal fistula, TEF: excessive cuff pressure causes erosion of the posterior wall of the trachea causing a hole between the Trach and anterior esophagus. Highest risk if a NG tube present
question
Prevention of TEF: maintain cuff pressure; monitor amount of air needed for inflation to detect changes; progress to a deflated or cuffless tube as soon as possible
answer
Management of TEF: manually administer oxygen by mask; use a small soft feeding tube instead of NG tube for feeding; A gastrostomy or Jejunostomy may be performed; monitor client with NG tube closely for TEF and aspiration
question
Manifestations: trach tube pulsates in synchrony with a heartbeat; heavy bleeding from the stoma; life-threatening
answer
Trachea - innominate artery fistula: a malpositioned tube causes it's distal tip to push against the lateral wall of the trachea causing necrosis and erosion of the Innominate artery. A medically emergency
question
Prevention: use correct tube size and length and maintain in midline position; prevent pulling or tugging of the tube; immediately notify Dr. of pulsating tube
answer
Management: remove trach immediately; apply direct pressure to the Innominate artery at the stoma site; prepare client for immediate surgery
