Nursing Care and Interventions Flashcards

A client has an NGT and is ordered tube feeding. Before starting, which action confirms correct tube placement?

Answer: Check pH of aspirate and verify tube length marking at the nose

Checking aspirate pH (gastric pH <5.5) and verifying tube length marking are evidence-based methods to confirm NGT placement.

A client has been ordered a glycerin suppository. Which action should be taken before insertion?

Answer: Warm to body temperature and lubricate with water-soluble lubricant

Warming a suppository prevents cold-induced anal sphincter spasm, and water-soluble lubricant facilitates smooth insertion.

When inserting a urinary catheter for a male client, the catheter meets resistance at the external urethral sphincter. What is the most appropriate action?

Answer: Ask the client to take a deep breath and relax, then gently advance

Deep breathing relaxes the external sphincter voluntarily, allowing gentle advancement without causing injury.

A client is prescribed subcutaneous heparin 5000 units. Which administration technique is most appropriate?

Answer: Inject into the abdomen 5 cm from the umbilicus, do not aspirate, do not massage

Subcutaneous heparin: inject into the abdomen (5 cm from navel), do not aspirate (increases bleeding risk), do not massage (causes bruising and alters absorption).

When changing a wound dressing, which finding requires immediate reporting?

Answer: A wound base that becomes deep red, firm, with surrounding pale indented tissue and foul odor

A deep red firm wound base with surrounding pale indentation and foul odor suggests wound infection, possible deep tissue injury, or necrotizing process.

When performing a 12-lead ECG, which electrode placement is correct for lead V4?

Answer: Fifth intercostal space at the midclavicular line

V4 is placed at the fifth intercostal space at the midclavicular line, corresponding to the apex of the heart.