Device-Related Complications (NG, Foley, Drains) - NCLEX-RN
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What complication is most directly caused by high continuous NG suction without replacement?
What complication is most directly caused by high continuous NG suction without replacement?
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Metabolic alkalosis from loss of gastric acid. Excessive removal of acidic gastric secretions depletes hydrogen ions without replacement, elevating blood pH.
Metabolic alkalosis from loss of gastric acid. Excessive removal of acidic gastric secretions depletes hydrogen ions without replacement, elevating blood pH.
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What is the priority action if a chest tube is accidentally pulled out of the patient?
What is the priority action if a chest tube is accidentally pulled out of the patient?
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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.
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.
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What is the priority action if a chest tube becomes disconnected from the drainage system?
What is the priority action if a chest tube becomes disconnected from the drainage system?
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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.
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.
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What is the priority action if a closed urinary drainage system becomes disconnected?
What is the priority action if a closed urinary drainage system becomes disconnected?
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Replace with a new sterile system (do not reconnect). Restores closed system integrity to prevent pathogen introduction from environmental exposure.
Replace with a new sterile system (do not reconnect). Restores closed system integrity to prevent pathogen introduction from environmental exposure.
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Which action is correct when collecting a urine specimen from a Foley catheter?
Which action is correct when collecting a urine specimen from a Foley catheter?
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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.
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.
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What is the priority action if urine is leaking around a Foley catheter (bypassing)?
What is the priority action if urine is leaking around a Foley catheter (bypassing)?
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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.
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.
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Which positioning of the urinary drainage bag is correct to prevent backflow?
Which positioning of the urinary drainage bag is correct to prevent backflow?
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Below bladder level and off the floor. Facilitates gravity drainage while preventing reflux of potentially contaminated urine into the bladder.
Below bladder level and off the floor. Facilitates gravity drainage while preventing reflux of potentially contaminated urine into the bladder.
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What is the correct action if a Foley catheter is accidentally pulled out with the balloon inflated?
What is the correct action if a Foley catheter is accidentally pulled out with the balloon inflated?
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Assess for bleeding, save catheter, and notify the provider. Evaluates for urethral trauma from balloon resistance and preserves device for provider examination.
Assess for bleeding, save catheter, and notify the provider. Evaluates for urethral trauma from balloon resistance and preserves device for provider examination.
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Which finding most strongly suggests a CAUTI rather than simple catheter irritation?
Which finding most strongly suggests a CAUTI rather than simple catheter irritation?
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Fever with suprapubic tenderness. Represents systemic inflammatory response and bladder involvement, distinguishing from local symptoms.
Fever with suprapubic tenderness. Represents systemic inflammatory response and bladder involvement, distinguishing from local symptoms.
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Which practice best reduces CAUTI risk in a patient with a Foley catheter?
Which practice best reduces CAUTI risk in a patient with a Foley catheter?
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Remove the catheter as soon as it is no longer indicated. Minimizes dwell time, reducing opportunity for bacterial colonization and biofilm formation.
Remove the catheter as soon as it is no longer indicated. Minimizes dwell time, reducing opportunity for bacterial colonization and biofilm formation.
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Which finding most strongly indicates an NG tube is in the trachea during insertion?
Which finding most strongly indicates an NG tube is in the trachea during insertion?
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Persistent coughing, choking, or respiratory distress. Indicates airway irritation and potential misplacement in the trachea rather than the esophagus during insertion.
Persistent coughing, choking, or respiratory distress. Indicates airway irritation and potential misplacement in the trachea rather than the esophagus during insertion.
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What is the most common device-related complication of an indwelling Foley catheter?
What is the most common device-related complication of an indwelling Foley catheter?
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Catheter-associated urinary tract infection (CAUTI). Indwelling catheters provide a pathway for bacterial ascension, increasing infection risk with duration.
Catheter-associated urinary tract infection (CAUTI). Indwelling catheters provide a pathway for bacterial ascension, increasing infection risk with duration.
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Which action is appropriate to relieve a Foley catheter occlusion from a clot when irrigation is ordered?
Which action is appropriate to relieve a Foley catheter occlusion from a clot when irrigation is ordered?
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Perform sterile catheter irrigation per protocol. Flushes obstructing material while maintaining sterility to restore patency without introducing infection.
Perform sterile catheter irrigation per protocol. Flushes obstructing material while maintaining sterility to restore patency without introducing infection.
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What is the priority nursing action when a Foley catheter stops draining and the bladder is distended?
What is the priority nursing action when a Foley catheter stops draining and the bladder is distended?
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Check for dependent loops/kinks and ensure drainage bag is below bladder. Corrects mechanical impediments to gravity-dependent urine flow, relieving retention and distension.
Check for dependent loops/kinks and ensure drainage bag is below bladder. Corrects mechanical impediments to gravity-dependent urine flow, relieving retention and distension.
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Which finding most suggests pressure injury from an NG tube at the nares?
Which finding most suggests pressure injury from an NG tube at the nares?
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Redness, ulceration, or skin breakdown at the nostril. Prolonged tube pressure against nasal tissue causes local ischemia, leading to tissue damage over time.
Redness, ulceration, or skin breakdown at the nostril. Prolonged tube pressure against nasal tissue causes local ischemia, leading to tissue damage over time.
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What is the priority action if a patient with an NG tube develops sudden severe epistaxis?
What is the priority action if a patient with an NG tube develops sudden severe epistaxis?
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Stop use and notify the provider immediately. Suggests nasal mucosa erosion or vessel damage from tube friction, requiring immediate medical intervention.
Stop use and notify the provider immediately. Suggests nasal mucosa erosion or vessel damage from tube friction, requiring immediate medical intervention.
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Which drain complication is suggested by sudden bright-red output and a falling blood pressure?
Which drain complication is suggested by sudden bright-red output and a falling blood pressure?
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Hemorrhage. Indicates active vascular bleeding near the drain site, causing hypovolemia and hemodynamic instability.
Hemorrhage. Indicates active vascular bleeding near the drain site, causing hypovolemia and hemodynamic instability.
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Which nursing action helps prevent aspiration during intermittent NG tube feedings?
Which nursing action helps prevent aspiration during intermittent NG tube feedings?
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Maintain head of bed at $30$–$45$ degrees. Elevates the upper body using gravity to minimize reflux of feedings into the esophagus and airways.
Maintain head of bed at $30$–$45$ degrees. Elevates the upper body using gravity to minimize reflux of feedings into the esophagus and airways.
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What is the priority intervention for an NG tube connected to suction that is not draining?
What is the priority intervention for an NG tube connected to suction that is not draining?
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Assess for kinks/occlusion and irrigate if ordered. Identifies mechanical blockages impeding drainage, restoring function to prevent nausea or distension.
Assess for kinks/occlusion and irrigate if ordered. Identifies mechanical blockages impeding drainage, restoring function to prevent nausea or distension.
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Which electrolyte imbalance is most associated with prolonged gastric suction via NG tube?
Which electrolyte imbalance is most associated with prolonged gastric suction via NG tube?
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Hypokalemia. Prolonged suction removes potassium-rich gastric fluid, leading to serum depletion if not replenished.
Hypokalemia. Prolonged suction removes potassium-rich gastric fluid, leading to serum depletion if not replenished.
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Which assessment finding suggests NG tube displacement after feeding has started?
Which assessment finding suggests NG tube displacement after feeding has started?
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New cough, dyspnea, or decreased oxygen saturation. Reflects possible aspiration of feedings into the lungs due to tube migration from the stomach.
New cough, dyspnea, or decreased oxygen saturation. Reflects possible aspiration of feedings into the lungs due to tube migration from the stomach.
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Which method is NOT reliable for confirming NG tube placement: auscultation of air bolus or X-ray?
Which method is NOT reliable for confirming NG tube placement: auscultation of air bolus or X-ray?
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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.
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.
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What is the priority nursing action if an NG tube is suspected to be in the airway?
What is the priority nursing action if an NG tube is suspected to be in the airway?
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Stop insertion immediately and remove the tube. Prevents further advancement into the respiratory tract, avoiding complications like aspiration or trauma.
Stop insertion immediately and remove the tube. Prevents further advancement into the respiratory tract, avoiding complications like aspiration or trauma.
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Which finding most suggests an air leak in a chest tube drainage system?
Which finding most suggests an air leak in a chest tube drainage system?
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Continuous bubbling in the water-seal chamber. Reflects persistent air entry from pleural space or system breach, unlike normal tidal fluctuations.
Continuous bubbling in the water-seal chamber. Reflects persistent air entry from pleural space or system breach, unlike normal tidal fluctuations.
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