Device-Related Complications (NG, Foley, Drains) - NCLEX Rn
- Which practice best reduces CAUTI risk in a patient with a Foley catheter?
- Remove the catheter as soon as it is no longer indicated. Minimizes dwell time, reducing opportunity for bacterial colonization and biofilm formation.
- Which finding most strongly suggests a CAUTI rather than simple catheter irritation?
- Fever with suprapubic tenderness. Represents systemic inflammatory response and bladder involvement, distinguishing from local symptoms.
- What is the priority action if a closed urinary drainage system becomes disconnected?
- Replace with a new sterile system (do not reconnect). Restores closed system integrity to prevent pathogen introduction from environmental exposure.
- What is the priority intervention for an NG tube connected to suction that is not draining?
- Assess for kinks/occlusion and irrigate if ordered. Identifies mechanical blockages impeding drainage, restoring function to prevent nausea or distension.
- Which positioning of the urinary drainage bag is correct to prevent backflow?
- Below bladder level and off the floor. Facilitates gravity drainage while preventing reflux of potentially contaminated urine into the bladder.
- Which electrolyte imbalance is most associated with prolonged gastric suction via NG tube?
- Hypokalemia. Prolonged suction removes potassium-rich gastric fluid, leading to serum depletion if not replenished.
- What is the priority nursing action if an NG tube is suspected to be in the airway?
- Stop insertion immediately and remove the tube. Prevents further advancement into the respiratory tract, avoiding complications like aspiration or trauma.
- Which nursing action helps prevent aspiration during intermittent NG tube feedings?
- Maintain head of bed at – degrees. Elevates the upper body using gravity to minimize reflux of feedings into the esophagus and airways.
- What complication is most directly caused by high continuous NG suction without replacement?
- Metabolic alkalosis from loss of gastric acid. Excessive removal of acidic gastric secretions depletes hydrogen ions without replacement, elevating blood pH.
- Which finding most suggests an air leak in a chest tube drainage system?
- Continuous bubbling in the water-seal chamber. Reflects persistent air entry from pleural space or system breach, unlike normal tidal fluctuations.
- Which drain complication is suggested by sudden bright-red output and a falling blood pressure?
- Hemorrhage. Indicates active vascular bleeding near the drain site, causing hypovolemia and hemodynamic instability.
- What is the priority action if a chest tube becomes disconnected from the drainage system?
- Place the tube end in sterile water and reestablish the system. Creates an emergency water seal to prevent atmospheric air influx into the pleural space and pneumothorax.
- What is the most common device-related complication of an indwelling Foley catheter?
- Catheter-associated urinary tract infection (CAUTI). Indwelling catheters provide a pathway for bacterial ascension, increasing infection risk with duration.
- What is the priority action if a patient with an NG tube develops sudden severe epistaxis?
- Stop use and notify the provider immediately. Suggests nasal mucosa erosion or vessel damage from tube friction, requiring immediate medical intervention.
- Which assessment finding suggests NG tube displacement after feeding has started?
- New cough, dyspnea, or decreased oxygen saturation. Reflects possible aspiration of feedings into the lungs due to tube migration from the stomach.
- Which action is correct when collecting a urine specimen from a Foley catheter?
- Use the sampling port with aseptic technique; do not use the bag. Obtains a fresh, uncontaminated sample from the catheter lumen, avoiding bag-related bacterial overgrowth.
- What is the priority action if urine is leaking around a Foley catheter (bypassing)?
- Assess for obstruction or bladder spasms; do not upsize routinely. Addresses underlying causes like clots or spasms that force urine past the balloon, avoiding unnecessary changes.
- Which action is appropriate to relieve a Foley catheter occlusion from a clot when irrigation is ordered?
- Perform sterile catheter irrigation per protocol. Flushes obstructing material while maintaining sterility to restore patency without introducing infection.
- What is the correct action if a Foley catheter is accidentally pulled out with the balloon inflated?
- Assess for bleeding, save catheter, and notify the provider. Evaluates for urethral trauma from balloon resistance and preserves device for provider examination.
- Which method is NOT reliable for confirming NG tube placement: auscultation of air bolus or X-ray?
- Auscultation of an air bolus is not reliable. Air bolus sounds can transmit falsely from the lungs to the epigastrium, leading to misconfirmation of placement.
- Which finding most strongly indicates an NG tube is in the trachea during insertion?
- Persistent coughing, choking, or respiratory distress. Indicates airway irritation and potential misplacement in the trachea rather than the esophagus during insertion.
- What is the priority nursing action when a Foley catheter stops draining and the bladder is distended?
- Check for dependent loops/kinks and ensure drainage bag is below bladder. Corrects mechanical impediments to gravity-dependent urine flow, relieving retention and distension.
- What is the priority action if a chest tube is accidentally pulled out of the patient?
- Apply an occlusive dressing taped on three sides and notify the provider. Acts as a flutter valve to allow pleural air escape while preventing entry, averting tension pneumothorax.
- Which finding most suggests pressure injury from an NG tube at the nares?
- Redness, ulceration, or skin breakdown at the nostril. Prolonged tube pressure against nasal tissue causes local ischemia, leading to tissue damage over time.