- A 56-year-old male is admitted to a medical-surgical unit with a small bowel obstruction and has a nasogastric tube to low intermittent suction for decompression placed 8 hours ago. He reports increasing nausea and abdominal distension. Vital signs: temperature 98.6°F (37.0°C), heart rate 104/min, blood pressure 148/86 mmHg, respirations 20/min; potassium 3.2 mEq/L. The nurse notes minimal drainage in the canister for the last 2 hours. Which intervention should be implemented to ensure catheter patency?
Answer: Assess the tubing for kinks and ensure the suction is on and set as prescribed, then reposition the client and recheck drainage
This question tests risk reduction in NG and urinary catheter care. The key risk in this scenario is nasogastric (NG) tube obstruction leading to inadequate decompression, worsening nausea, and potential aspiration in a patient with small bowel obstruction. Assessing the tubing for kinks, ensuring the suction is on and set as prescribed, repositioning the client, and rechecking drainage effectively reduces the risk by restoring patency and promoting gastric emptying. Advancing the tube (A) without verification could cause trauma; increasing suction (B) may damage mucosa; irrigating without an order (D) is outside scope and risks complications. A key principle of catheter care is regularly checking equipment functionality to maintain patency and prevent blockages. Another principle is avoiding unauthorized interventions to ensure patient safety and adherence to orders. A strategy for monitoring includes observing drainage amount and character hourly and assessing abdominal distension to detect early complications like obstruction or displacement.
- Which action is essential to maintain tube patency and client safety?
Answer: Flush the tube with 15 to 30 mL of water before and after the medication.
Flushing the NG tube with 15 to 30 mL of water immediately before medication administration confirms tube patency and clears the tube of any residual formula that could react with the medication. Flushing after administration ensures the entire medication dose reaches the stomach and clears the tube to prevent clogging, which is the most common mechanical complication of enteral tubes. If multiple medications are given, each should be administered separately with a flush between them. Mixing medication with enteral formula (A) can cause physical incompatibilities, alter drug absorption, and clog the tube. A 3 mL syringe (C) creates excessive pressure that can rupture small-bore tubes — a minimum 30 to 60 mL syringe should be used. Clamping the tube after medication (D) is not standard practice and is contraindicated if the tube is providing ongoing decompression.
- Which statement by the client indicates a need for further instruction?
Answer: "I will wait until my bladder is very full and painful before I try to go."
Waiting until the bladder is 'very full and painful' before voiding indicates a need for further teaching. Clients should be instructed to respond to the urge to void promptly — typically when the bladder contains 150 to 300 mL — rather than suppressing the urge until the bladder is maximally distended. Chronic over-distension weakens the detrusor muscle, can cause temporary post-catheter urinary retention or difficulty voiding, and increases the risk of urinary tract infection. After catheter removal, the nurse monitors for the client's first void within 4 to 6 hours and volume of at least 200 mL. Choices A (adequate hydration), B (reporting voiding difficulty — which could indicate urinary retention after catheter removal), and D (proper perineal hygiene technique) are all correct self-care behaviors that do not require correction.
- Which intervention should the nurse include in the immediate plan of care to address the obstruction?
Answer: Perform a manual irrigation of the catheter with sterile normal saline.
Post-TURP catheter obstruction is most commonly caused by a blood clot lodging at the catheter tip or within the drainage channel. Manual irrigation with sterile normal saline using a piston syringe is the definitive intervention to mechanically dislodge and flush the clot, restoring outflow. This is an expected and standard nursing skill in post-TURP care. Slowing the CBI rate (B) slightly reduces the rate of fluid accumulation but does not address the existing clot obstruction — the bladder will continue to distend, just more slowly. Increasing oral fluids (C) is completely counterproductive in an obstructed system — adding more fluid when drainage is blocked worsens distension. Prone positioning (D) has no therapeutic effect on catheter obstruction and is inappropriate for a post-operative client with a fresh surgical site.
- Which action should the nurse take first?
Answer: Re-instill the residual and delay the feeding for one hour.
A gastric residual volume of 150 mL combined with the subjective report of bloating indicates that the client is not adequately digesting the previous feeding and the stomach has not emptied. Adding a bolus feeding on top of an already distended stomach increases the risk of aspiration, vomiting, and abdominal discomfort. The aspirate should be re-instilled into the tube before clamping: this preserves electrolytes and digestive enzymes that would be lost if discarded. The feeding is then delayed for approximately one hour, after which gastric residual is re-checked. The nurse should notify the PHCP if residuals remain elevated at the next assessment or if the client develops worsening symptoms. Proceeding with the feeding despite a high residual (A or B) risks aspiration. Supine positioning (D) is contraindicated for tube feedings — the head of the bed should be elevated at least 30 to 45 degrees.
- Which action should the nurse take to maintain the client's skin integrity?
Answer: Clean the skin around the nose and re-secure the tube daily.
Daily NG tube site care involves cleaning the skin around the naris with soap and water or a prescribed antiseptic, assessing the nasal mucosa for signs of pressure injury or irritation, and re-securing the tube with fresh tape or a commercial tube holder — repositioning the point of skin contact slightly to redistribute pressure. This prevents breakdown of the delicate nasal mucosa and naris that are subject to constant pressure from the tube. Taping to the forehead (A) is not a standard or appropriate site for NG tube securement and would create an unusual tube angle causing mucosal pressure. Petroleum jelly inside the nostrils (C) can degrade tape adhesive, increase aspiration risk if applied excessively, and is not standard site care. Leaving old tape in place for a week (D) allows skin maceration, adhesive buildup, and accumulated pressure injury under the tape.
- How should the nurse determine the correct length of the tube to be inserted?
Answer: Measure from the tip of the nose to the earlobe, then to the xiphoid process.
The NEX measurement — Nose to Earlobe to Xiphoid process — is the standard method for estimating the insertion length required to position the distal tip of a nasogastric tube in the stomach. This external anatomical landmark measurement accounts for individual variation in anatomy and provides a reliable estimate of the distance from the naris to the gastric body. The measured length is marked on the tube; the tube is considered correctly positioned when this mark reaches the naris. Tube placement must then be confirmed before use by X-ray (most reliable), pH testing of aspirate (pH 5 or less suggests gastric placement), or auscultation as a secondary check. Measuring to the umbilicus (B) would insert the tube too far, potentially into the small bowel. A standard 50 cm length for all adults (C) does not account for individual anatomical variation. Measuring from the mouth (D) is not the established reference point for nasal insertion.
- Which clinical finding is the most significant indicator that the urinary catheter system is obstructed?
Answer: The report of severe, sharp pain and a strong urge to urinate.
Severe, sharp lower abdominal pain combined with a strong urge to urinate in a client with an indwelling catheter are the primary clinical cues of bladder distension from catheter obstruction. These symptoms occur because the bladder continues to fill with irrigation fluid but cannot drain, creating rapid and painful over-distension. When the nurse subsequently confirms absent drainage and palpable bladder distension (at 1005), the cues align into a clear obstruction presentation. The client's age (A) is a demographic factor that increases surgical risk but does not indicate obstruction. Light pink drainage earlier (C) was an expected and reassuring post-TURP finding — a change from this normal baseline toward absent drainage is the alert. The type of catheter (B) explains the clinical setup but is not a finding indicating obstruction.
- Which action should the nurse take first?
Answer: Check the tubing for any kinks or dependent loops of fluid.
When an NG tube connected to suction produces no drainage, the nurse must systematically troubleshoot from the least invasive step first. Checking for kinks, dependent loops of fluid in the tubing, or disconnections in the system takes only seconds, does not require touching the client's tube, and can immediately identify the most common cause of drainage loss. If no mechanical obstruction is found, the nurse can then irrigate with 30 mL of sterile normal saline (C) to check tube patency. Increasing to high continuous suction (A) without first investigating the cause risks mucosal injury if the tube is against the gastric wall. Notifying the provider (B) is appropriate if simpler troubleshooting steps fail, but checking for kinks must come first.
- Which action is a priority for the nurse during this procedure?
Answer: Fully deflate the balloon using a 10 mL syringe before withdrawal.
The retention balloon must be fully deflated before the catheter is withdrawn to prevent urethral trauma. A 10 mL syringe is attached to the inflation port and the saline is aspirated until the syringe fills and no resistance remains, confirming complete deflation. The catheter can then be gently withdrawn. Cutting the inflation port (A) is a dangerous technique that is not recommended: if the cut is made below the one-way valve, the valve may prevent deflation and the balloon can remain inflated, causing urethral injury during withdrawal. Even if the balloon partially deflates, fragments or a misshapen balloon can cause trauma. Breath-holding (C) is not a standard technique and serves no protective purpose during catheter removal. Rapid withdrawal (D) is painful and increases urethral trauma risk — the catheter should be removed smoothly and at a consistent, gentle pace.
- Based on the assessment of bladder distension and lack of output, which nursing hypothesis is the priority?
Answer: Impaired urinary elimination related to mechanical obstruction.
Impaired urinary elimination related to mechanical obstruction is the priority hypothesis because it represents the most immediate physiological threat: the bladder is actively distending with fluid that cannot exit, creating risk of tissue injury, hemorrhage, and bladder rupture. Every nursing action at this point is directed at relieving the obstruction and restoring drainage. Risk for infection (B) is a valid ongoing concern for any catheterized client but is not the acute emergency here — infection develops over time, not in the current moment. Acute pain (C) is a real and present finding, but it is a symptom of the obstruction — addressing the obstruction will resolve the pain. Addressing pain independently while leaving the obstruction in place does not eliminate the safety risk. Deficient knowledge (D) is an educational concern for the discharge planning phase, not the acute crisis.
- Following the irrigation, a large blood clot was removed and 500 mL of reddish-pink fluid drained into the bag. The client states pain is now 1 out of 10. The nurse determines the intervention was successful because:
Answer: The bladder is no longer distended and output has resumed.
The two direct outcome measures for catheter obstruction management are the relief of bladder distension (confirming the obstruction is cleared) and the resumption of drainage into the collection bag (confirming the system is patent). Both are present: 500 mL of fluid has drained and the client's pain has decreased from severe to 1/10 — consistent with decompression of the distended bladder. Completely clear urine (A) is not a realistic or expected finding on post-operative Day 1 after TURP; reddish-pink drainage is expected for days as the surgical site heals. Ambulation (C) may be a post-operative goal but is not a measure of catheter obstruction resolution. A faster irrigation rate (D) is not the treatment goal and may indicate the system has been adjusted incorrectly rather than restored safely.
- The nurse should recognize these findings as potential indicators of:
Answer: Aspiration of the enteral feeding into the lungs.
A new, frequent cough and decreasing oxygen saturation in a client receiving NG tube feedings are critical warning signs of pulmonary aspiration — entry of feeding formula into the tracheobronchial tree. Aspiration can cause aspiration pneumonia, which is a serious, potentially fatal complication. The nurse must immediately stop the feeding, position the client upright, suction the airway if needed, notify the PHCP, and prepare for further evaluation including chest X-ray. A new, frequent cough is not an expected response to an NG tube (B) — while mild, occasional throat clearing can occur, a frequent productive cough with falling SpO2 is abnormal and clinically significant. A nasal infection (C) would produce localized nasal symptoms (discharge, tenderness) but not new cough and oxygen desaturation. Formula concentration (D) has no relationship to cough or oxygenation status.
- The nurse is performing the manual irrigation. Which action by the nurse ensures safe and effective care?
Answer: Use a sterile 60 mL piston syringe to instill the saline gently.
Manual bladder irrigation must be performed using sterile technique to prevent introducing bacteria into a post-surgical urinary tract. A 60 mL piston (Asepto) syringe is the appropriate device — it provides enough volume to flush effectively with controlled, gentle pressure. The saline is instilled slowly and smoothly; resistance should be noted and force should never be used. Non-sterile tap water (A) introduces microbial contamination risk into a sterile closed system. Forceful instillation of 100 mL (C) is highly dangerous in a fresh TURP client: the raw surgical site can be traumatized, suture lines disrupted, and the bladder injured by excessive pressure. Irrigation fluid is documented as irrigation fluid intake and output — not as oral intake (B); these are recorded separately and subtracted from output to calculate net urinary output.
- Which information is most important for the nurse to include in the medical record?
Answer: The size of the catheter, the amount of fluid in the balloon, and the urine characteristics.
Complete documentation for an indwelling urinary catheter insertion must include: the catheter size (French size), which affects future catheter changes and care planning; the volume of sterile water used to inflate the retention balloon, confirming the balloon was properly inflated; and characteristics of the initial urine output — color (straw-colored, yellow, blood-tinged), clarity, and approximate volume — which establishes a baseline for ongoing monitoring. This information provides the clinical data future care providers need to assess catheter function and urine changes over time. While client anxiety (A) may be documented as a brief subjective note, it is not a clinical priority in catheter insertion documentation. Manufacturer name (C) is not clinically relevant documentation. The exact time the sterile field setup began (B) is procedural detail not routinely required — the procedure time and completion are the relevant temporal data points.
- What is the most appropriate nursing action?
Answer: Unclamp the NG tube and reconnect it to the prescribed suction.
Nausea and abdominal distension while the NG tube is clamped indicate that the client is not tolerating the clamped state — gastric motility is insufficient to move contents through the GI tract, and the stomach is accumulating gas and fluid. The appropriate response is to unclamp the tube and restore suction, which will immediately relieve the accumulation and reduce the risk of vomiting and aspiration. The PHCP should also be notified of the client's intolerance to the clamped state. Ambulation (A) may help overall GI motility but will not provide the immediate decompression needed for active nausea and distension. An antiemetic (C) may be appropriate as a comfort measure but does not address the underlying cause — the stomach needs to be decompressed, not just pharmacologically quieted. Waiting two hours (D) creates an unacceptable safety risk for a client with increasing distension who may vomit and aspirate.
- A 80-year-old female is scheduled to have her indwelling urinary catheter removed today after 3 days following surgery. She has a history of recurrent urinary tract infections. Vital signs: temperature 98.3°F (36.8°C), heart rate 74/min, blood pressure 116/62 mmHg, respirations 16/min. Which action should the nurse take to reduce the risk of infection during catheter removal?
Answer: Perform hand hygiene, don clean gloves, deflate the balloon completely, and remove the catheter smoothly without forcing
This question tests risk reduction in NG and urinary catheter care. The key risk in this scenario is infection during urinary catheter removal in a patient with recurrent UTIs. Performing hand hygiene, donning clean gloves, deflating the balloon completely, and removing smoothly effectively reduces the risk by minimizing bacterial introduction. Cutting the catheter (B) is unsafe; instilling antiseptic (C) is not standard; delegating to UAP (D) is inappropriate. A key principle of catheter care is aseptic technique during removal. Another principle is ensuring full deflation to prevent trauma. A strategy for monitoring includes post-removal voiding assessment to detect retention or infection early.
- The nurse should identify these findings as indicators of:
Answer: A potential catheter-associated urinary tract infection (CAUTI).
Cloudy urine, foul odor, and periurethral burning or itching in a catheterized client constitute a classic presentation of catheter-associated urinary tract infection (CAUTI). These findings occur because bacteria ascending along the catheter surface colonize the bladder, producing pyuria (white cells that cloud the urine) and bacterial metabolites that create the characteristic odor. The nurse must obtain a urine culture specimen and notify the PHCP for evaluation and possible antibiotic therapy. Concentrated urine from low intake (A) is darker yellow but remains clear, not cloudy — cloudiness indicates cellular or bacterial content, not concentration alone. An allergic reaction to insertion antiseptic (C) would present as a local skin reaction at the time of insertion, not days later with urinary changes. While discomfort from catheter presence (D) is real, cloudy foul urine is never a 'standard side effect' and always warrants investigation.
- A 60-year-old female with bowel obstruction has a nasogastric tube to low intermittent suction for decompression, in place for 20 hours. The nurse notes the client is repeatedly swallowing and complaining of nausea; the suction canister shows no output for 3 hours. Vital signs: temperature 98.8°F (37.1°C), heart rate 106/min, blood pressure 146/90 mmHg, respirations 20/min. Which action should the nurse take IMMEDIATELY to reduce the risk of complications?
Answer: Assess the suction equipment and tubing for disconnection or kinks and ensure prescribed suction is functioning
This question tests risk reduction in NG and urinary catheter care. The key risk in this scenario is nasogastric tube malfunction causing nausea and potential aspiration from lack of decompression. Assessing the suction equipment and tubing for disconnection or kinks and ensuring prescribed suction is functioning effectively reduces the risk by restoring drainage. Administering antiemetic (B) treats symptom; offering fluids (C) risks aspiration; removing tube (D) is unauthorized. A key principle of catheter care is equipment checks for patency. Another principle is immediate troubleshooting. A strategy for monitoring includes hourly drainage and symptom assessment to detect malfunctions early.
- A 72-year-old female in an acute rehab unit has an indwelling urinary catheter (14 Fr) for 5 days after a stroke due to urinary retention. The nurse notes the drainage bag is resting on the floor during transfer back to bed. Vital signs: temperature 98.7°F (37.1°C), heart rate 80/min, blood pressure 130/76 mmHg, respirations 16/min. Which action should the nurse take to reduce the risk of infection?
Answer: Hang the drainage bag on the bed frame below bladder level without allowing it to touch the floor
This question tests risk reduction in NG and urinary catheter care. The key risk in this scenario is infection from contamination when the drainage bag touches the floor, potentially introducing bacteria. Hanging the drainage bag on the bed frame below bladder level without allowing it to touch the floor effectively reduces the risk by preventing microbial ascent and promoting gravity drainage. Emptying into the toilet (B) risks splashing; disconnecting (C) opens the system; clamping (D) causes stasis. A key principle of catheter care is keeping the bag off the floor and below the bladder to control infection. Another principle is maintaining a closed system for patency and hygiene. A strategy for monitoring includes checking bag position during transfers and assessing urine clarity to detect early contamination.
