Nutrition

A nurse is preparing to perform a dressing change to the site of a patient's central venous catheter used for parenteral nutrition. Which equipment and supplies would the nurse need to gather? Select all that apply.

Masks Skin antiseptic Alcohol wipes Sterile gauze pads

The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance?

260

A nurse is aware of the high incidence of catheter-related bloodstream infections in clients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections?

Change the dressing no more than weekly.

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN?

Checking the client's capillary blood glucose levels regularly

A nurse is caring for a client with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The client's oxygen saturation is 89% by pulse oximetry. After ensuring the client's immediate safety, what is the nurse's most appropriate action?

Report possible signs of aspiration pneumonia to the primary provider.

A nurse is caring for a client with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this client, what nursing diagnosis should the nurse prioritize?

Risk for Infection Related to the Presence of a Subclavian Catheter

A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube.

Sit the client in an upright position Apply gloves to the nurse's hands Measure the length of the tube that will be inserted Apply water-soluble lubricant to the tip of the tube Tilt the client's nose upward Instruct the client to lower the head and swallow

Before inserting a gastric or enteric tube, the nurse determines the length of tubing that will be needed to reach the stomach or small intestine. The Levin tube, a commonly used nasogastric tube, has circular markings at specific points. This tube should be inserted to 6 to 10 cm beyond what length?

The distance measured from the tip of the nose (N) to the earlobe (E) and from the earlobe to the xiphoid (X) process

The nurse is caring for a client who is postoperative from having a gastrostomy tube placed. What should the nurse do on a daily basis to prevent skin breakdown?

gently rotate the tube

The most significant complication related to continuous tube feedings is

increased potential for aspiration

A client is receiving continuous tube feedings at 75 mL/hr. The nurse has checked the residual volume 4 hours ago as 250 mL. The nurse now assesses the residual volume as 325 mL. The first action of the nurse is to

notify the physician

A nurse is creating a care plan for a client with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube?

Use a combination of at least two accepted methods for confirming placement.

A client receives tube feedings after an oral surgery. The nurse manages tube feedings to minimize the risk of aspiration. Which measure should the nurse include in the care plan to reduce the risk of aspiration?

Use semi-Fowler position during, and 60 minutes after, an intermittent feeding.

The nurse confirms placement of a client's nasogastric (NG) tube using a combination of visual and pH assessment of the aspirate. The nurse determines that the NG tube remains properly placed when the pH of the aspirate is

acidic

The primary source of microorganisms for catheter-related infections are the skin and the

catheter hub

What type of feedings should be administered to a client who is at risk of diarrhea due to hypertonic feeding solutions?

continuous feedings

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for:

diaphoresis, vomiting, and diarrhea

The nurse prepares to administer all of a client's medications via feeding tube. The nurse consults the pharmacist and/or physician when the nurse notes which type of oral medication on the client's medication administration record?

enteric-coated tablets

The nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. What is the main purpose of these nursing actions?

prevent aspiration

The client is receiving 50% dextrose parenteral nutrition with fat emulsion therapy through a peripherally inserted central catheter (PICC). The nurse has developed a care plan for the nursing diagnosis "Risk for infection related to contamination of the central catheter site or infusion line." The nurse includes the intervention

wear a face mask during dressing changes