Tracheostomy
PEG & Enteral Feeding
Foley & Urinary Care
Medications
Respiratory & Cardiac
100

A patient with a tracheostomy has noisy, gurgling respirations and visible secretions. What should the nurse do?  

  • Suction the tracheostomy.
  • Clear the airway of accumulated secretions.
  • Assess the patient's respiratory status and oxygenation.
100

What positioning is appropriate while a patient is receiving a PEG tube feeding?

  • Keep the head of the bed elevated at least 30 degrees.
  • An upright position is preferred when possible.
  • Maintain elevation after the feeding according to facility policy.
100

A patient's urine output suddenly decreases even though the patient has adequate fluid intake. What should the nurse check?

  • Inspect the tubing for kinks.
  • Check for compression or obstruction.
  • Make sure the drainage bag is positioned correctly.
  • Check whether urine is flowing freely.
100

A patient refuses a prescribed medication. What should the nurse do?

  • Ask the patient why they are refusing.
  • Listen to their concerns.
  • Provide appropriate education.
  • Respect the patient's right to refuse.
  • Notify the provider when required.
  • Document the refusal and appropriate interventions.
100

What are the purposes of an incentive spirometer after surgery?

  • Encourages deep breathing.
  • Promotes lung expansion.
  • Helps prevent atelectasis.
  • Helps improve ventilation.
  • Can assist with mobilizing respiratory secretions.
200

During tracheostomy care, the nurse notices thick, yellow-green drainage around the stoma. What should the nurse do?

  • Notify the healthcare provider.
  • Assess the stoma and surrounding skin.
  • Monitor for other signs of infection.
  • Document the drainage and assessment findings.
200

Why should enteral formula generally be given at room temperature?

  • Helps prevent abdominal discomfort.
  • Can reduce cramping.
  • May improve gastrointestinal tolerance.
200

Where should the Foley drainage bag be kept?

  • Below the level of the bladder.
  • Off the floor.
  • In a position that allows urine to drain freely.
200

What should the nurse look for during medication reconciliation?

  • Medication omissions.
  • Duplicate medications.
  • Incorrect doses.
  • Unintended medication changes.
  • Allergies.
  • Differences between the patient's medication list and current orders.
200

What instructions should a patient receive when learning to use an incentive spirometer?

  • Sit upright.
  • Seal the lips around the mouthpiece.
  • Inhale slowly and deeply through the device.
  • Hold the breath for several seconds.
  • Perform repeated breaths as instructed, commonly about 10 times per hour while awake.
300

Why is humidification important for a patient with a tracheostomy?

  • Keeps secretions moist.
  • Prevents secretions from becoming thick and difficult to remove.
  • Helps maintain airway patency.
  • Makes coughing and secretion clearance easier.
300

Why should a PEG tube be flushed with water after formula or medication administration?

  • Maintains tube patency.
  • Helps prevent clogging.
  • Clears remaining medication or formula from the tube.
  • Keeps the tube functional.
300

What nursing practices help reduce the risk of a catheter-associated urinary tract infection?

  • Perform hand hygiene before and after catheter care.
  • Maintain a closed drainage system.
  • Keep the drainage bag below bladder level.
  • Avoid unnecessary disconnections.
  • Perform appropriate perineal hygiene.
300

What actions promote medication safety when using an automated medication dispensing system?

  • Use your own login credentials.
  • Verify the patient's identity.
  • Check the medication.
  • Verify the dose.
  • Confirm the route.
  • Confirm the administration time.
  • Check allergies.
  • Perform required medication-label checks.
300

What should the nurse monitor during a nebulizer treatment?

  • Oxygen saturation.
  • Respiratory rate.
  • Heart rate.
  • Breath sounds.
  • Respiratory effort.
  • Patient response to treatment.
400

A nurse is suctioning a tracheostomy and applies suction while inserting the catheter. Why is this incorrect?

  • Suction should be applied during withdrawal, not insertion.
  • Applying suction during insertion can damage the airway mucosa.
  • It can increase trauma and irritation.
400

How can the initial placement of a newly inserted PEG tube be verified?

  • Radiographic confirmation/X-ray is the preferred initial method.
  • Follow the facility's approved verification procedure before starting feedings.
400

A patient complains of discomfort from a Foley catheter during transportation. What should the nurse check?

  • Look for kinks in the tubing.
  • Check for obstruction.
  • Make sure the tubing isn't being pulled.
  • Verify that the drainage bag is positioned correctly.
  • Assess the patient for bladder distention or other causes of discomfort.
400

What needle characteristics are appropriate when giving a thin medication subcutaneously?

  • A relatively high-gauge needle.
  • A small-bore needle.
  • A needle appropriate for the medication and injection route.
400

A patient becomes dizzy and faint during a nebulizer treatment. What should the nurse do?

  • Stop the nebulizer treatment.
  • Assess the patient's condition.
  • Check vital signs.
  • Assess respiratory status.
  • Determine whether additional intervention is needed.
500

The skin beneath a patient's tracheostomy ties is becoming irritated and broken down. What should the nurse assess or do?

  • Check the fit of the tracheostomy ties.
  • Assess whether the ties are too tight.
  • Reposition or adjust the ties as appropriate.
  • Assess the skin for worsening breakdown.
  • Reduce pressure and friction on the affected area.
500

What is dumping syndrome, and what symptoms can occur with it?

  • Rapid emptying of stomach contents into the small intestine.
  • Abdominal cramping.
  • Diarrhea.
  • Nausea.
  • Weakness or discomfort after feeding.
500

What are important considerations when removing an indwelling Foley catheter?

  • Completely deflate the balloon.
  • Explain the procedure to the patient.
  • Remove the catheter gently.
  • Monitor the patient afterward for urinary problems.
500

What should the nurse consider when administering a thick or viscous medication?

  • A larger-bore needle may be appropriate.
  • A lower-gauge needle may make administration easier.
  • The needle must still be appropriate for the medication and route.
500

A patient with atrial fibrillation has shortness of breath and dependent edema. What could explain these findings?

  • Reduced cardiac output.
  • Ineffective atrial contractions.
  • Reduced ventricular filling.
  • Fluid accumulation related to impaired cardiac function.
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