NCLEX Practice Exam for Patient Tubes (NGT, Chest, and Tracheostomy)

EXPLANATION

✔Correct answer:

2-4 cm. The endotracheal tube (ETT) should be positioned 2-4 cm above the carina to ensure proper placement and effective ventilation. The carina is the point at which the trachea divides into the left and right mainstem bronchi. Positioning the tube 2-4 cm above the carina ensures that the tube is far enough away to avoid irritation or damage to the carina but close enough to provide optimal ventilation to both lungs. This placement helps prevent the tube from migrating into one of the bronchi, which would result in ventilation of only one lung (most commonly the right lung), leading to inadequate oxygenation and potential complications.

The carina is a sensitive area that, when stimulated, can cause coughing or bronchospasm. If the ETT is positioned too close to the carina or beyond it, there is a risk that the tube could enter one of the main bronchi, leading to unilateral lung ventilation. This would decrease oxygenation and could cause atelectasis (collapse) of the unventilated lung. Conversely, if the ETT is placed too far above the carina, it risks becoming dislodged into the oropharynx, leading to the loss of airway protection and potential aspiration.

Imagine a sprinkler system designed to water a garden. To water all the plants evenly, the sprinkler needs to be positioned in the center, not too close to one side. Similarly, the ETT should be positioned centrally, a few centimeters above the carina, to ensure both lungs receive proper ventilation.

After confirming the tube’s position on the chest x-ray, Nurse Johnson should:

• Secure the ETT to prevent movement that could alter its position.
• Continue to monitor the patient’s respiratory status, including breath sounds, oxygen saturation, and ventilator settings.
• Be vigilant for signs of tube misplacement, such as asymmetrical chest rise or decreased breath sounds on one side, which could indicate that the tube has shifted.
• Document the ETT’s position in centimeters at the teeth or lips to ensure it remains in the correct position over time.
• Reassess and verify the tube’s placement periodically and whenever the patient is moved or repositioned.

✘Incorrect answers:

1.5-3 cm. Although this range is close, it is narrower than the generally accepted 2-4 cm range, potentially risking either too close or too far placement from the carina.

1-2 cm. This distance is too close to the carina and increases the risk of irritation or accidental migration into one of the bronchi, leading to potential complications.

0.5-1 cm. This distance is much too close to the carina, significantly increasing the risk of bronchial intubation or irritation, which could cause serious complications like bronchospasm or unilateral lung ventilation.

EXPLANATION

✔Correct answer:

The student cuts the dressing to fit around the tracheostomy tube. Nurse Carter should intervene if the student nurse cuts the tracheostomy dressing to fit around the tube. Pre-cut or specially designed tracheostomy dressings should always be used. Cutting a dressing can lead to the formation of loose fibers or threads that might enter the tracheostomy site, increasing the risk of infection or obstruction. These loose fibers can be aspirated into the trachea, potentially leading to complications such as respiratory distress or infection.

The tracheostomy site is a direct entry point to the patient's airway, making it highly susceptible to infection. Any loose material or foreign objects can easily be inhaled, leading to respiratory complications. Therefore, using a pre-cut, sterile tracheostomy dressing is crucial for preventing such risks and ensuring the integrity of the stoma site.

Think of the tracheostomy site like an open window. If you cover the window with a blanket that sheds fibers, those fibers can easily blow into the room (airway). Similarly, cutting a dressing can create loose threads that might enter the trachea, which could cause serious problems.

To ensure the safety and effectiveness of tracheostomy care, Nurse Carter should provide the following instructions:

• Always use a sterile, pre-cut tracheostomy dressing specifically designed for this purpose to avoid introducing loose fibers or contaminants into the stoma site.
• Educate the student nurse on the potential risks associated with cutting dressings, including the risk of infection and airway obstruction.
• Ensure that the student nurse understands the importance of maintaining a sterile field and using the correct materials when performing tracheostomy care.
• Regularly assess the tracheostomy site for signs of infection, irritation, or displacement, and ensure that the dressing is changed appropriately.

✘Incorrect answer options:

The student uses sterile technique while cleaning around the stoma. Using sterile technique to clean around the stoma is correct and necessary to prevent infection at the tracheostomy site. This action does not require intervention.

The student removes the inner cannula for cleaning. Removing the inner cannula for cleaning is a standard part of tracheostomy care to prevent occlusion and maintain patency of the airway. This action is appropriate.

The student applies a new tracheostomy dressing under the flange. Applying a new tracheostomy dressing under the flange is correct practice and helps to absorb any drainage and protect the skin around the stoma. This action is appropriate and does not require intervention.

EXPLANATION

✔Correct answer:

Pouring the formula into the tube as quickly as possible to prevent clogging. It is inappropriate to pour the formula into the nasogastric tube as quickly as possible. Administering a bolus enteral feeding too rapidly can lead to complications such as abdominal cramping, nausea, vomiting, diarrhea, and even aspiration, particularly in a comatose patient who is unable to protect their airway. The feeding should be administered slowly and steadily to allow the body to properly absorb the nutrients and reduce the risk of these adverse effects. The feeding rate should follow the physician's or dietitian's recommendations to ensure patient safety and comfort.

When enteral nutrition is delivered too quickly, it can overwhelm the stomach's capacity to handle and digest the feeding, leading to increased gastric residuals and the risk of aspiration, especially in patients with compromised consciousness or impaired gag reflexes. Rapid administration can also cause osmotic diarrhea, where the intestines pull in water to dilute the concentrated formula, leading to loose stools and dehydration.

Think of the stomach as a sponge soaking up liquid. If you pour too much water too quickly, the sponge can’t absorb it all, and the excess spills over. Similarly, the stomach needs time to "soak up" the nutrition from a feeding to avoid overflow and complications.

When administering a bolus enteral feeding, Nurse Rivera should:

• Administer the feeding slowly over a period of time, as directed by the healthcare provider, typically over 15-20 minutes for a bolus feed.
• Monitor the patient for any signs of discomfort, bloating, or signs of feeding intolerance during the administration.
• Ensure that the tube is flushed with water before and after the feeding to maintain patency and prevent clogging.
• Maintain the patient’s head of the bed elevated at least 30 degrees before, during, and after the feeding to reduce the risk of aspiration.
• Document the procedure, including the rate of administration, patient tolerance, and any measures taken to ensure safe feeding.

✘Incorrect answer options:

Checking the pH of the gastric aspirate to confirm tube placement. Correct. Checking the pH of the gastric aspirate is an appropriate and recommended method to confirm that the NG tube is correctly placed in the stomach before administering the feeding.

Elevating the head of the bed to at least 30 degrees before feeding. Correct. Elevating the head of the bed helps prevent aspiration, a critical safety measure for enteral feeding, especially in a comatose patient.

Flushing the tube with water before and after the feeding. Correct. Flushing the tube helps maintain tube patency, prevents clogging, and ensures that the entire feeding is delivered effectively without leaving residue in the tube.

EXPLANATION

✔Correct answer:

Hold the retention sutures to open the stoma. If the tracheostomy tube becomes dislodged, the immediate priority is to maintain an open airway. The first action Nurse Patel should take is to hold the retention sutures to keep the stoma open. This action ensures that the stoma does not close, which would result in a blocked airway and respiratory distress. By keeping the stoma open, the nurse can prevent life-threatening complications and provide an accessible route for reinsertment of the tracheostomy tube or a temporary airway if needed.

A tracheostomy provides a direct airway through an opening in the trachea. If the tube becomes dislodged, the stoma (the opening in the neck) can rapidly close due to tissue elasticity, swelling, or the absence of a secure tube. Holding the retention sutures pulls the edges of the stoma apart, maintaining patency of the airway and allowing for immediate intervention.

Think of the tracheostomy stoma like an open door in a hallway that needs to stay open for air to pass through. If the door starts to close (like the stoma potentially closing after the tube is dislodged), you need to immediately hold it open to keep the passage clear. Holding the retention sutures is like placing a doorstop to keep the door (stoma) open, ensuring that air can continue to flow freely through the trachea.

After ensuring the stoma is held open by the retention sutures, the nurse must take further steps to stabilize the patient and prevent further complications. Below are some essential nursing actions that should follow immediately after securing the airway:

• Ensure the retention sutures are accessible and not tangled or obstructed during tracheostomy care.
• After holding the retention sutures, the nurse should immediately call for assistance to reinsert the tracheostomy tube.
• If the tube cannot be reinserted promptly, the nurse should be prepared to initiate emergency airway management, including the use of a bag-valve mask over the stoma or the patient’s mouth if necessary.
• Keep emergency tracheostomy supplies at the bedside, including a spare tracheostomy tube of the same size and one size smaller.
• Continuously monitor the patient’s respiratory status and oxygen saturation during the incident.

✘Incorrect answer options:

Contact the respiratory therapist to reinsert the tracheostomy tube. While contacting the respiratory therapist is necessary, it should not be the first action. Maintaining the patency of the stoma and the patient’s airway takes immediate precedence.

Place a sterile dressing over the tracheostomy site. Placing a sterile dressing over the site may obscure the airway and is inappropriate in this emergency situation. The airway must be kept open, not covered.

Notify the physician to reinsert the tracheostomy tube. Like contacting the respiratory therapist, notifying the physician is important but not the first priority. The immediate focus must be on ensuring the patient can breathe by keeping the stoma open.

EXPLANATION

✔Correct answer:

5.5. A pH level of 5.5 would indicate that the nasogastric tube is correctly positioned in the stomach, even for a patient on long-term Omeprazole (Prilosec) therapy. Normally, the gastric pH is quite acidic, typically around 1 to 4. However, Omeprazole, a proton pump inhibitor (PPI), works by reducing the production of stomach acid, which can increase the gastric pH. In patients on Omeprazole, the gastric pH may be slightly higher, but a pH of 5.5 still suggests that the tube is in the stomach.

Omeprazole suppresses the secretion of gastric acid by inhibiting the enzyme system (H+/K+ ATPase) in the stomach lining responsible for acid production. This leads to a higher gastric pH compared to patients who are not on acid-suppressing therapy. Despite this, the pH should still be lower than that of respiratory secretions (typically greater than 6), making a pH of 5.5 indicative of gastric placement.

Think of the stomach like a swimming pool that normally has very acidic water. If you add a lot of baking soda (like Omeprazole), the water becomes less acidic, but it’s still more acidic than tap water. Similarly, even with Omeprazole, the stomach’s pH is still more acidic than that of the lungs or intestines.

After verifying the tube placement, Nurse Stevens should:

• Document the pH value and the amount and characteristics of the aspirated gastric contents.
• Ensure that the tube is properly secured to prevent displacement during feedings or medications.
• Continue to monitor the patient for any signs of improper tube placement, such as coughing, difficulty breathing, or unexpected changes in respiratory status.
• Consider obtaining radiographic confirmation if there is any doubt about the tube’s placement.
• Flush the tube with water before and after administering feedings or medications to maintain patency.

✘Incorrect answer options:

7.75. A pH of 7.75 is too high to be gastric. This pH is more likely associated with respiratory secretions, indicating that the tube may be in the lungs, which would be unsafe.

7.5. A pH of 7.5 is also too high for stomach contents, even for a patient on Omeprazole. This level is more consistent with secretions from the respiratory tract or intestines, not the stomach.

6.5. Although closer, a pH of 6.5 is still higher than what is typically expected in the stomach, even with acid suppression. It could suggest the tube is not in the stomach but possibly in the intestines or respiratory tract.

EXPLANATION

✔Correct answer:

The Levin tube is a double-lumen nasogastric tube with an air vent. Nurse Adams should clarify that the Levin tube is not a double-lumen nasogastric tube with an air vent. The Levin tube is actually a single-lumen nasogastric tube, and it does not have an air vent. The tube is primarily used for gastric decompression, medication administration, and feeding. Since it lacks an air vent, it carries a higher risk of mucosal damage due to suction pressure. In contrast, the Salem Sump tube is the one with a double lumen—one lumen is used for suction, and the other, a smaller "piggyback" lumen, functions as an air vent to prevent the tube from adhering to the stomach lining and causing injury.

Nasogastric tubes are used for various purposes, including decompression of the stomach, administration of medications or enteral nutrition, and lavage. The design and features of each type of tube are specific to its intended use. Understanding the differences between them is crucial for safe and effective patient care, particularly in preventing complications like mucosal damage or aspiration.

Think of the Levin tube as a single straw, while the Salem Sump tube is like a double straw—one part to drink and the other to let air in, preventing a vacuum that could damage the cup (or in this case, the stomach lining).

When using a nasogastric tube, the nurse should:

• Identify the correct type of tube for the patient’s specific needs.
• Ensure proper placement of the tube before initiating use, typically confirmed by X-ray or pH testing of aspirated gastric contents.
• Monitor for complications, such as mucosal irritation, blockage, or incorrect placement.
• Educate the patient on the purpose and function of the tube.
• Document the type of tube used, the placement verification process, and any relevant patient responses.

✘Incorrect answer options:

The Cantor tube is a single-lumen long tube with a small inflatable bag at the distal end. This is correct. The Cantor tube is used for decompression of the intestines and has a weighted, inflatable bag at the end to help it advance through the gastrointestinal tract.

The Miller-Abbott tube is a long double-lumen used for draining and decompressing the small intestine. This is correct. The Miller-Abbott tube is a double-lumen tube designed for decompression of the small intestine. One lumen is for balloon inflation, and the other is for aspiration.

The Sengstaken-Blakemore tube is a three-lumen tube. This is correct. The Sengstaken-Blakemore tube is used primarily to manage esophageal varices bleeding and has three lumens: one for gastric balloon inflation, one for esophageal balloon inflation, and one for gastric aspiration.

EXPLANATION

✔Correct answer:

There is a leak. The most likely reason that a patient with an endotracheal tube (ETT) is able to make verbal sounds is that there is a leak. The ETT is designed to sit just above the carina in the trachea and, when properly positioned, the cuff is inflated to create a seal that prevents air from passing around the tube. If the cuff is underinflated or there is a defect, air can escape around the tube, allowing the patient to produce sounds, including speech. This air leak not only compromises the effectiveness of ventilation but also increases the risk of aspiration and may indicate that the cuff is not adequately securing the airway.

The primary purpose of the cuff on an endotracheal tube is to create a seal in the trachea, ensuring that all ventilated air is directed into the lungs and preventing secretions from entering the lungs. If the cuff is not fully inflated or is leaking, air can escape past the tube and reach the vocal cords, allowing the patient to produce sound. This situation is not normal and requires immediate attention to avoid complications such as inadequate ventilation or aspiration pneumonia.

Imagine a balloon with a small hole in it. When you blow air into the balloon, some air escapes through the hole, preventing the balloon from inflating fully. Similarly, if there’s a leak around the endotracheal tube cuff, air escapes, allowing the patient to make sounds instead of directing all the air into the lungs.

Upon noticing verbal sounds from a patient with an endotracheal tube, Nurse Harris should:

• Check the cuff pressure to ensure it is within the recommended range (usually between 20-30 cm H₂O) to maintain a proper seal.
• Listen for other signs of an air leak, such as a hissing sound near the patient’s mouth or neck, or decreased ventilation pressures.
• Notify the respiratory therapist and/or physician if a leak is suspected so that the tube can be assessed and adjusted if necessary.
• Monitor the patient for signs of respiratory distress, such as decreased oxygen saturation, increased work of breathing, or restlessness, which may indicate inadequate ventilation.
• Document the findings, interventions, and the patient’s response in the medical record.

✘Incorrect answer options:

This is a normal finding. Verbal sounds in a patient with an endotracheal tube are not normal. The presence of sound typically indicates a problem, such as a cuff leak.

There is an occlusion. An occlusion in the endotracheal tube would block air from passing through the tube, leading to signs of respiratory distress, not allowing the patient to make sounds.

The endotracheal tube is displaced. If the endotracheal tube were displaced above the vocal cords, it would compromise the airway and likely result in respiratory distress, not just the ability to make sounds. This situation requires immediate intervention but is different from a simple cuff leak.

EXPLANATION

✔Correct answer:

Position the tube at the tip of the nose, then measure by extending it to the earlobe and down to the xiphoid process. To accurately measure the length of a nasogastric (NG) tube before insertion, Nurse Taylor should position the tube at the tip of the nose (nare), then extend it to the earlobe, and down to the xiphoid process (the bottom of the sternum). This measurement ensures that the NG tube is long enough to pass through the nose, down the esophagus, and into the stomach without being too short or too long, which could lead to improper placement.

Proper measurement and placement of the NG tube are critical to ensure that it reaches the stomach and does not coil in the esophagus or enter the respiratory tract. The correct method of measuring from the nose to the earlobe and then to the xiphoid process provides an accurate estimate of the tube length needed to safely reach the stomach. An improperly placed NG tube can cause serious complications, such as aspiration, trauma to the nasal or esophageal mucosa, or placement in the lungs, leading to respiratory distress.

Think of it like threading a needle through fabric. You measure the thread to ensure it’s long enough to pass through all the layers but not so long that it tangles or gets in the way.

After measuring the NG tube:

• Lubricate the tip of the tube to ease insertion and reduce discomfort.
• Have the patient flex their head forward once the tube reaches the oropharynx to help guide the tube down the esophagus.
• Monitor for any signs of respiratory distress during insertion, which could indicate misplacement of the tube into the trachea.
• Confirm placement of the tube by checking the pH of the aspirated gastric contents or obtaining an X-ray before using the tube for feeding or medication administration.
• Document the procedure, including the measurement method, insertion process, and confirmation of tube placement.

✘Incorrect answer options:

Position the tube at the tip of the nose, then measure by extending it to the earlobe and down to the top of the sternum. Measuring to the top of the sternum (manubrium) instead of the xiphoid process would result in an NG tube that is too short, potentially leading to improper placement.

Position the tube at the tip of the nose, then measure by extending it down to the chin and then down to the top of the xiphoid process. Measuring from the chin instead of the earlobe is not the correct method and would not provide an accurate length for safe and effective placement in the stomach.

Position the tube at the base of the nose, then measure by extending it to the earlobe and down to the top of the sternum. Measuring from the base of the nose instead of the tip and to the top of the sternum instead of the xiphoid process would result in an incorrect tube length.

EXPLANATION

✔Correct answer:

Take a deep breath and hold it. Nurse Patel should instruct the patient to take a deep breath and hold it just before removing the nasogastric (NG) tube. This technique is recommended because it closes the glottis, which helps prevent aspiration of any residual gastric contents during the tube removal. By holding their breath, the patient reduces the risk of inhaling or aspirating any contents that may still be in the tube or the stomach, ensuring a safer removal process.

During the removal of an NG tube, there is a potential risk for aspiration, especially in patients with compromised swallowing or airway protective mechanisms, such as those recovering from a stroke. Closing the glottis by holding the breath minimizes this risk by creating a temporary barrier that prevents any fluids or contents from being inhaled into the lungs.

Imagine you're about to unplug a vacuum cleaner hose. To avoid dust and debris from flying back into the air, you cover the hose’s opening just before pulling it out. Similarly, when a patient holds their breath during NG tube removal, it's like closing off their airway "hose," preventing any unwanted fluids from being inhaled while the tube is gently pulled out.

While removing the NG tube, Nurse Patel should:

• Ensure the tube is flushed with a small amount of air or saline to clear any remaining gastric contents before removal.
• Instruct the patient to take a deep breath and hold it as the tube is smoothly and quickly withdrawn.
• Monitor the patient for any signs of discomfort, coughing, or respiratory distress during and after the procedure.
• Inspect the tube after removal to ensure it is intact and that no pieces have been left behind.
• Document the procedure, including the patient’s response and any relevant observations.

✘Incorrect answer options:

Inhale and exhale at the same time. It is physiologically impossible to inhale and exhale simultaneously. This instruction would be confusing and ineffective in preventing aspiration during NG tube removal.

Perform a Valsalva maneuver. The Valsalva maneuver involves forcibly exhaling against a closed airway, which could increase intrathoracic pressure and is not recommended during NG tube removal. It does not effectively prevent aspiration.

Blow the nose. Blowing the nose is unrelated to the safe removal of an NG tube and does not prevent aspiration. It could also cause discomfort or complications if performed during or immediately after the removal process.

EXPLANATION

✔Correct answer:

Take no action, as this is a normal and expected finding. Continuous gentle bubbling in the suction control chamber of a chest tube drainage system is an expected and normal finding. This indicates that the suction is functioning correctly and that the system is helping to remove air from the pleural space, which is necessary for the re-expansion of the lung in a patient with a pneumothorax. The gentle bubbling shows that there is a controlled amount of suction being applied to the chest tube system, and it is effectively removing air.

A pneumothorax occurs when air accumulates in the pleural space, causing the lung to collapse. A chest tube connected to a drainage system is used to remove this air and allow the lung to re-expand. The suction control chamber, usually filled with water, regulates the amount of negative pressure applied. Gentle bubbling in this chamber confirms that suction is being applied and is removing the trapped air effectively.

Think of the suction control chamber like a straw in a glass of water. If you blow gently through the straw, you create small, steady bubbles in the water, which is similar to the gentle bubbling in the chamber. This shows that everything is working smoothly, just as the gentle bubbling indicates that the chest tube system is operating correctly.

It is important for Nurse Thompson to continue monitoring the patient and the chest tube system to ensure proper function. Additional steps include:

• Regularly check the water levels in the suction control chamber to ensure it remains at the prescribed level, as evaporation can reduce the effectiveness of the suction.
• Observe for any sudden changes in bubbling patterns, which might indicate an air leak or other issues that would require further investigation.
• Monitor the patient's respiratory status, oxygen saturation, and lung sounds to assess for improvement or worsening of the pneumothorax.
• Ensure that the chest tube and drainage system are securely connected and free of kinks or obstructions that could compromise the drainage process.
• Educate the patient about the function of the chest tube and the importance of reporting any sudden changes in breathing or discomfort.

✘Incorrect answer options:

Increase the suction pressure to create more vigorous bubbling. Increasing the suction pressure is unnecessary and could be harmful. Vigorous bubbling in the suction control chamber is not required and could lead to increased negative pressure, which may cause damage to the lung tissue or pleura.

Clamp the chest tube immediately and inform the physician. Clamping the chest tube without a specific reason (such as during tube removal or in the case of an air leak) is not appropriate and could lead to a dangerous build-up of air or fluid in the pleural space, worsening the pneumothorax.

Inspect for an air leak since bubbling should occur only intermittently. Continuous gentle bubbling in the suction control chamber is expected. Intermittent or continuous bubbling in the water seal chamber, not the suction control chamber, would be a cause for concern and could indicate an air leak.

EXPLANATION

✔Correct answer:

Submerge the end of the chest tube in a container of sterile normal saline. If a chest drainage system becomes accidentally disconnected, Nurse Adams should immediately submerge the end of the chest tube in a container of sterile normal saline. This action is crucial because it helps create a temporary water seal, which prevents air from being drawn back into the pleural space, reducing the risk of a pneumothorax (air in the pleural space) or a tension pneumothorax, which can be life-threatening.

The chest tube is placed to remove air, blood, or other fluids from the pleural space and allow the lung to re-expand. If the chest tube is disconnected, air can potentially re-enter the pleural space, leading to lung collapse or worsening of the patient's condition. Submerging the tube in sterile saline mimics the function of the water seal chamber in the chest drainage system, preventing air from entering while still allowing for some drainage of air or fluid.

Imagine the chest tube is like a straw used to suck air out of a container to keep it from collapsing. If the straw gets disconnected, air might rush back in and cause the container to collapse. By placing the straw in a glass of water (or in this case, sterile saline), you prevent air from rushing back in while still allowing the container to stay stable.

After submerging the chest tube in sterile saline, Nurse Adams should take the following steps to ensure the patient’s safety:

• Re-establish the connection with a new sterile chest drainage system as soon as possible.
• Continuously monitor the patient’s respiratory status, including breathing patterns, oxygen saturation, and lung sounds, to detect any signs of respiratory distress.
• Ensure the patient is comfortable and provide reassurance, explaining the steps being taken to correct the situation.
• Notify the physician or healthcare provider immediately after securing the temporary water seal.
• Document the incident, actions taken, and the patient's response in the medical record.

✘Incorrect answer options:

Secure the chest tube with tape. Simply taping the chest tube will not prevent air from entering the pleural space and can lead to serious complications. A water seal is necessary to prevent air from re-entering the chest.

Immediately clamp the chest tube. Clamping the chest tube is generally avoided because it can trap air or fluid in the pleural space, increasing the risk of a tension pneumothorax, which is a medical emergency.

Apply an occlusive dressing and notify the physician. Applying an occlusive dressing may be appropriate if the chest tube is removed from the chest wall, not when the drainage system is disconnected. In the case of disconnection, the priority is to re-establish the water seal, not to cover the tube.

EXPLANATION

✔Correct answer:

Coughing out blood. Nurse Thompson should immediately notify the physician if the patient is coughing out blood after the removal of the endotracheal tube. Hemoptysis, or coughing up blood, can be a sign of serious complications such as tracheal injury, trauma to the airway or lungs, or other significant issues like infection or bleeding disorders. This symptom warrants prompt evaluation and intervention by the healthcare provider to determine the underlying cause and initiate appropriate treatment.

Hemoptysis following extubation can occur due to several factors, including trauma to the tracheal mucosa during the intubation or extubation process, which can cause bleeding. It could also indicate a more severe condition such as tracheal laceration, bronchial damage, or even a bleeding disorder that may have been exacerbated by the procedure. Immediate assessment and management are crucial to prevent further complications, such as airway obstruction or significant blood loss.

Imagine you're driving a car and suddenly see red warning lights on the dashboard—this signals a serious problem that needs immediate attention. Similarly, coughing up blood after extubation is like a red warning light for the patient’s airway health, requiring urgent medical evaluation.

After notifying the physician, Nurse Thompson should:

• Monitor the patient’s vital signs closely, including oxygen saturation, heart rate, and respiratory rate.
• Observe the amount and frequency of blood being coughed up, as well as any associated symptoms such as shortness of breath or chest pain.
• Prepare the patient for further diagnostic tests or interventions, such as a chest X-ray or bronchoscopy, if ordered by the physician.
• Provide supportive care, including maintaining a patent airway and ensuring the patient is comfortable and calm.
• Document the findings, interventions, and the patient's response in the medical record.

✘Incorrect answer options:

Sore throat. A sore throat is a common and expected finding after endotracheal extubation due to irritation of the throat and vocal cords from the tube.

Hoarseness of the voice. Hoarseness is also common post-extubation as the vocal cords may be swollen or irritated from the tube, leading to temporary changes in voice quality.

Neck discomfort. Some neck discomfort can occur due to the position of the head and neck during intubation and extubation, as well as from the presence of the tube itself.

EXPLANATION

✔Correct answer:

Reinstill the residual and proceed with the feeding. Nurse Williams should reinstill the residual and proceed with the feeding. Gastric residual volumes (GRVs) are checked to assess the patient's tolerance to enteral feeding. A residual of 90 mL is generally considered low and within a safe range to continue feeding. Most guidelines suggest that if the residual is less than 200-250 mL, it is appropriate to return the residual contents to the stomach and proceed with the scheduled feeding. Returning the residual is important because it contains essential nutrients, electrolytes, and digestive enzymes, which are important for maintaining the patient’s nutritional status and gastrointestinal function.

The stomach naturally holds and processes food and fluids, and some residual is expected as part of this process. The residual volume helps assess whether the stomach is effectively emptying its contents into the small intestine. A higher residual might indicate delayed gastric emptying, but a low residual, like 90 mL, suggests that the stomach is functioning well enough to proceed with feeding. Discarding the residual unnecessarily would result in the loss of important nutrients and could contribute to malnutrition, especially in patients dependent on enteral feeding for their caloric intake.

Think of gastric residuals like checking the gas tank in a car. If there's a small amount of fuel left, you wouldn’t drain it out before refilling the tank; you’d simply add more fuel to keep the car running smoothly. Similarly, in the stomach, a small residual volume is like that remaining fuel—it’s safe to add more (feed the patient) without discarding what’s already there, ensuring the body has the nutrients it needs to keep "running" effectively.

After reinstilling the residual and proceeding with the feeding, Nurse Williams should:

• Document the amount of residual and the decision to continue feeding.
• Monitor the patient for any signs of feeding intolerance, such as nausea, vomiting, or abdominal distention.
• Ensure the head of the bed remains elevated to at least 30-45 degrees during and after feeding to reduce the risk of aspiration.
• Reassess gastric residuals as per the facility’s protocol to continuously monitor tolerance to enteral feeding.
• Communicate any concerns or significant findings to the healthcare provider, especially if residual volumes increase significantly.

✘Incorrect answer options:

Discard the residual amount. Discarding the residual would result in a loss of important nutrients and digestive fluids, which can be detrimental to the patient's nutritional status.

Hold the scheduled feeding. Holding the feeding unnecessarily could lead to inadequate nutrition, especially if done without clear clinical indications. A residual of 90 mL does not typically warrant holding the feeding.

Skip the feeding and give the next one in 4 hours. Skipping a feeding based on a 90 mL residual is inappropriate and could contribute to underfeeding and malnutrition, especially in patients relying on enteral nutrition for their caloric intake.

EXPLANATION

✔Correct answer:

A drainage volume of 100 mL is observed in the collection chamber. Nurse Williams should be concerned about a drainage volume of 100 mL in the collection chamber if it occurs within a short period of time. In a patient with hemothorax, excessive drainage—typically more than 70-100 mL per hour—can indicate ongoing bleeding into the pleural space. This requires immediate notification of the physician, as it may necessitate urgent intervention, such as surgery or adjustment of the treatment plan.

A hemothorax involves the accumulation of blood in the pleural space, which can compress the lung and impair breathing. Chest tubes are used to drain this blood, allowing the lung to re-expand. While some drainage is expected, a large volume in a short time may suggest active bleeding, which can lead to hypovolemic shock and other serious complications if not addressed promptly.

Imagine you have a sponge that’s slowly absorbing water from a spill. If the sponge suddenly becomes soaked and water starts pouring out rapidly, it’s a sign that the spill has gotten much worse. Similarly, a sudden spike in the chest tube drainage volume is like the sponge becoming overwhelmed, indicating that the bleeding in the chest is worsening and needs immediate attention.

If Nurse Williams observes a drainage volume of 100 mL or more in a short timeframe, the following steps should be taken:

• Immediately notify the physician or the healthcare team about the excessive drainage.
• Monitor the patient's vital signs closely, especially blood pressure, heart rate, and oxygen saturation, to assess for signs of hypovolemia or shock.
• Document the drainage volume, color, and consistency, and continue to monitor drainage trends to identify any further increases.
• Ensure that the chest tube system remains intact, with no kinks or obstructions that might affect the drainage.
• Prepare for potential interventions, such as blood transfusions, imaging studies, or surgical procedures, as directed by the physician.

✘Incorrect answer options:

Movement of water in the water seal chamber with each breath. This is known as "tidaling" and is a normal finding that indicates the chest tube is functioning properly. The water in the seal chamber should rise and fall with the patient’s breaths.

The drainage system is positioned below the patient’s chest level. The drainage system should always be positioned below chest level to facilitate gravity drainage of fluid and air from the pleural space. This is the correct position and does not require any action.

An occlusive dressing covers the chest tube insertion site. An occlusive dressing is appropriate and necessary to prevent air from entering the pleural space, which could lead to a pneumothorax. This is an expected and correct practice, not a cause for concern.

EXPLANATION

✔Correct answer:

24 hours. Continuous feedings through a nasogastric tube are typically administered over 24 hours. Continuous enteral feeding involves the slow and steady delivery of nutrients to the patient over a full day, usually at a controlled rate through an infusion pump. This method is often used for patients who cannot tolerate large volumes of feeding at once, such as those with compromised gastric function, critically ill patients, or those at risk of aspiration.

Continuous feeding provides a constant flow of nutrition that is easier for the body to handle compared to bolus or intermittent feedings, which deliver larger volumes over shorter periods. This method helps to maintain stable blood glucose levels, prevent dumping syndrome, and reduce the risk of gastrointestinal discomfort, including nausea, vomiting, and diarrhea. It also decreases the likelihood of aspiration in patients who may have difficulty with gastric emptying or who are bedridden.

Continuous feeding is like a slow drip watering system for plants—steady and consistent, ensuring the plant gets the right amount of water throughout the day without overwhelming it.

When administering a continuous feeding, Nurse Simmons should:

• Set the infusion pump to the prescribed rate, ensuring that the total volume is delivered evenly over 24 hours.
• Monitor the patient for signs of feeding intolerance, such as abdominal distention, nausea, vomiting, or increased gastric residuals.
• Keep the patient’s head of the bed elevated to at least 30-45 degrees during feeding and for 30-60 minutes afterward to reduce the risk of aspiration.
• Check gastric residual volumes as per facility protocol, typically every 4 to 6 hours, to ensure proper gastric emptying and tolerance.
• Document the feeding rate, the patient’s tolerance, and any interventions taken in response to findings during the feeding period.

✘Incorrect answers:

4 hours. A 4-hour feeding would be more typical of an intermittent or bolus feeding, not a continuous feeding.

12 hours. While some continuous feedings might be administered over 12 hours (often overnight), the standard continuous feeding typically runs over 24 hours.

36 hours. Feedings are generally not administered continuously over more than 24 hours. The feeding set and tubing should be changed every 24 hours to prevent bacterial contamination and infection.