CPNRE Nursing Care and Interventions 2 — Questions and Answers
Question 1: A client has an NGT and is ordered tube feeding. Before starting, which action confirms correct tube placement?
- Inject air and listen with a stethoscope
- Check pH of aspirate and verify tube length marking at the nose (Correct answer)
- Auscultate for bowel sounds in all four quadrants
- Verify by feeling resistance when injecting water
Correct 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.
Evidence-based NGT placement verification (IPAC Canada, RNAO best practice guideline): aspirate stomach contents and check pH (gastric aspirate pH <5.5 confirms gastric placement; pH >6 may indicate respiratory placement); verify external tube length marking matches documented insertion length. The auscultation method (air 'whoosh' test) is no longer considered reliable and has been removed from Canadian practice guidelines. Radiographic confirmation (x-ray) is the gold standard for initial placement and when there is doubt. Every feed should include pH check and length verification. Feeding into a misplaced NGT can cause aspiration pneumonia, lung injury, or death.
Question 2: A client has been ordered a glycerin suppository. Which action should be taken before insertion?
- Warm to body temperature and lubricate with water-soluble lubricant (Correct answer)
- Refrigerate immediately before use to firm it
- Crush and dilute in water for administration
- Administer with a glass of warm water for faster effect
Correct 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.
Rectal suppository administration: allow to reach room temperature or warm briefly between hands (prevents anal sphincter spasm from cold); use water-soluble lubricant (not petroleum-based); don gloves; position client in left lateral (Sims') position; insert rounded end first past the internal anal sphincter (approximately 7-10 cm in adults); ask client to retain 20-30 minutes; document insertion and subsequent bowel movement. Suppositories should never be crushed (destroys the slow-release matrix). Refrigeration is for storage, not insertion preparation.
Question 3: When inserting a urinary catheter for a male client, the catheter meets resistance at the external urethral sphincter. What is the most appropriate action?
- Apply firm pressure to advance past the resistance
- Ask the client to take a deep breath and relax, then gently advance (Correct answer)
- Remove and attempt a smaller gauge catheter
- Call the physician since male catheterization is beyond scope
Correct 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.
The external urethral sphincter is under voluntary control and can be relaxed by deep breathing. When resistance is encountered: ask the client to take a slow, deep breath; instruct to relax the pelvic floor as if urinating; gently rotate and advance smoothly. NEVER force the catheter against resistance (can cause urethral trauma, false passages, perforation). Male urinary catheterization is within the scope of practice for practical nurses in Canadian provinces with appropriate education and competence. If resistance persists despite relaxation, notify the physician for possible prostate evaluation.
Question 4: A client is prescribed subcutaneous heparin 5000 units. Which administration technique is most appropriate?
- Aspirate before injection and massage vigorously after
- Inject into the abdomen 5 cm from the umbilicus, do not aspirate, do not massage (Correct answer)
- Inject into the deltoid muscle and apply pressure
- Aspirate before each injection
Correct 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).
Subcutaneous heparin technique: preferred site is the abdomen, at least 5 cm from the umbilicus, iliac crests, and incisions; 25-gauge, 5/8 or 3/8 inch needle at 90 degrees (or 45 degrees for thin clients); do NOT aspirate (creates trauma and increases hematoma risk); inject medication; do NOT massage (breaks down clot at injection site, alters absorption, increases bruising); apply gentle pressure with dry gauze; document site rotation. LMWH (enoxaparin/Lovenox, dalteparin/Fragmin) follow the same technique. Commonly prescribed in Canadian acute care for DVT prophylaxis and treatment.
Question 5: When changing a wound dressing, which finding requires immediate reporting?
- Serosanguinous drainage consistent with previous documentation
- Wound edges that appear approximated and pink
- A wound base that becomes deep red, firm, with surrounding pale indented tissue and foul odor (Correct answer)
- Wound size that has slightly decreased from previous measurement
Correct 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.
The described findings raise concern for deep wound infection, possible necrotizing fasciitis (rapidly progressing, life-threatening), deep tissue pressure injury, or vascular compromise. These require immediate physician notification. Normal healing: pink/red granulation tissue, decreasing exudate, decreasing wound size. Warning signs requiring urgent reporting: odor; unusual discoloration; perilesional pale/dusky discoloration; increased pain; tissue firmness; visible tissue breakdown. Practical nurses must accurately assess and document wounds using standardized tools (Bates-Jensen Wound Assessment Tool used in Canadian facilities) and know when to escalate.
Question 6: When performing a 12-lead ECG, which electrode placement is correct for lead V4?
- Fourth intercostal space, right sternal border
- Fourth intercostal space, left sternal border
- Fifth intercostal space at the midclavicular line (Correct answer)
- Anterior axillary line, same level as V4
Correct 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.
Standard 12-lead ECG precordial lead placement: V1: 4th ICS right sternal border; V2: 4th ICS left sternal border; V3: between V2 and V4 diagonally; V4: 5th ICS midclavicular line (apex of heart); V5: anterior axillary line, same level as V4; V6: midaxillary line, same level as V4/V5. Limb leads: RA, LA, RL (ground), LL. Incorrect lead placement causes waveform distortion leading to potential misinterpretation. V4 at the cardiac apex is critical for anterior wall MI diagnosis. Practical nurses must know correct ECG lead placement per Canadian nursing competency standards.
CPNRE Nursing Care and Interventions 2
A client has an NGT and is ordered tube feeding.
Before starting, which action confirms correct tube placement?