Nclexrn Flashcards: Device Related Complications Ng Foley Drains

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This deck focuses on Device Related Complications Ng Foley Drains, giving you a quick way to review the definitions, rules, and examples that matter most for Nclexrn.

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Flashcard 1: Which practice best reduces CAUTI risk in a patient with a Foley catheter?

Answer: Remove the catheter as soon as it is no longer indicated. Minimizes dwell time, reducing opportunity for bacterial colonization and biofilm formation.

Flashcard 2: Which finding most strongly suggests a CAUTI rather than simple catheter irritation?

Answer: Fever with suprapubic tenderness. Represents systemic inflammatory response and bladder involvement, distinguishing from local symptoms.

Flashcard 3: What is the priority action if a closed urinary drainage system becomes disconnected?

Answer: Replace with a new sterile system (do not reconnect). Restores closed system integrity to prevent pathogen introduction from environmental exposure.

Flashcard 4: What is the priority intervention for an NG tube connected to suction that is not draining?

Answer: Assess for kinks/occlusion and irrigate if ordered. Identifies mechanical blockages impeding drainage, restoring function to prevent nausea or distension.

Flashcard 5: Which positioning of the urinary drainage bag is correct to prevent backflow?

Answer: Below bladder level and off the floor. Facilitates gravity drainage while preventing reflux of potentially contaminated urine into the bladder.

Flashcard 6: Which electrolyte imbalance is most associated with prolonged gastric suction via NG tube?

Answer: Hypokalemia. Prolonged suction removes potassium-rich gastric fluid, leading to serum depletion if not replenished.

Flashcard 7: What is the priority nursing action if an NG tube is suspected to be in the airway?

Answer: Stop insertion immediately and remove the tube. Prevents further advancement into the respiratory tract, avoiding complications like aspiration or trauma.

Flashcard 8: Which nursing action helps prevent aspiration during intermittent NG tube feedings?

Answer: Maintain head of bed at $30$–$45$ degrees. Elevates the upper body using gravity to minimize reflux of feedings into the esophagus and airways.

Flashcard 9: What complication is most directly caused by high continuous NG suction without replacement?

Answer: Metabolic alkalosis from loss of gastric acid. Excessive removal of acidic gastric secretions depletes hydrogen ions without replacement, elevating blood pH.

Flashcard 10: Which finding most suggests an air leak in a chest tube drainage system?

Answer: Continuous bubbling in the water-seal chamber. Reflects persistent air entry from pleural space or system breach, unlike normal tidal fluctuations.

Flashcard 11: Which drain complication is suggested by sudden bright-red output and a falling blood pressure?

Answer: Hemorrhage. Indicates active vascular bleeding near the drain site, causing hypovolemia and hemodynamic instability.

Flashcard 12: What is the priority action if a chest tube becomes disconnected from the drainage system?

Answer: 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.

Flashcard 13: What is the most common device-related complication of an indwelling Foley catheter?

Answer: Catheter-associated urinary tract infection (CAUTI). Indwelling catheters provide a pathway for bacterial ascension, increasing infection risk with duration.

Flashcard 14: What is the priority action if a patient with an NG tube develops sudden severe epistaxis?

Answer: Stop use and notify the provider immediately. Suggests nasal mucosa erosion or vessel damage from tube friction, requiring immediate medical intervention.

Flashcard 15: Which assessment finding suggests NG tube displacement after feeding has started?

Answer: New cough, dyspnea, or decreased oxygen saturation. Reflects possible aspiration of feedings into the lungs due to tube migration from the stomach.

Flashcard 16: Which action is correct when collecting a urine specimen from a Foley catheter?

Answer: 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.

Flashcard 17: What is the priority action if urine is leaking around a Foley catheter (bypassing)?

Answer: 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.

Flashcard 18: Which action is appropriate to relieve a Foley catheter occlusion from a clot when irrigation is ordered?

Answer: Perform sterile catheter irrigation per protocol. Flushes obstructing material while maintaining sterility to restore patency without introducing infection.

Flashcard 19: What is the correct action if a Foley catheter is accidentally pulled out with the balloon inflated?

Answer: Assess for bleeding, save catheter, and notify the provider. Evaluates for urethral trauma from balloon resistance and preserves device for provider examination.

Flashcard 20: Which method is NOT reliable for confirming NG tube placement: auscultation of air bolus or X-ray?

Answer: 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.

Flashcard 21: Which finding most strongly indicates an NG tube is in the trachea during insertion?

Answer: Persistent coughing, choking, or respiratory distress. Indicates airway irritation and potential misplacement in the trachea rather than the esophagus during insertion.

Flashcard 22: What is the priority nursing action when a Foley catheter stops draining and the bladder is distended?

Answer: Check for dependent loops/kinks and ensure drainage bag is below bladder. Corrects mechanical impediments to gravity-dependent urine flow, relieving retention and distension.

Flashcard 23: What is the priority action if a chest tube is accidentally pulled out of the patient?

Answer: 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.

Flashcard 24: Which finding most suggests pressure injury from an NG tube at the nares?

Answer: Redness, ulceration, or skin breakdown at the nostril. Prolonged tube pressure against nasal tissue causes local ischemia, leading to tissue damage over time.