Chapter 45: Digestive and Gastrointestinal Treatment Modalities
The nurse is caring for a patient who has dumping syndrome from high carbohydrate foods being administered over a period of less than 20 minutes. What is a nursing measure to prevent or minimize the dumping syndrome? a) Administer the feeding with the patient in semi-Fowler's position to decrease transit time influenced by gravity. b) Administer the feeding at a warm temperature to decrease peristalsis. c) Administer the feeding with about 100 mL of fluid to dilute the high carbohydrate concentration. d) Administer the feeding by bolus to prevent continuous intestinal distention.
a) Administer the feeding with the patient in semi-Fowler's position to decrease transit time influenced by gravity. The following strategies may help prevent some of the uncomfortable signs and symptoms of dumping syndrome related to tube feeding: Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. Administer feedings at room temperature, because temperature extremes stimulate peristalsis. Administer feeding by continuous drip (if tolerated) rather than by bolus, to prevent sudden distention of the intestine. Advise the patient to remain in semi-Fowler's position for 1 hour after the feeding; this position prolongs intestinal transit time by decreasing the effect of gravity. Instill the minimal amount of water needed to flush the tubing before and after a feeding, because fluid given with a feeding increases intestinal transit time.
When assessing whether a patient is a candidate for home parenteral nutrition, which of the following would be important to address? Select all that apply. a) Motivation for learning b) Health status c) Telephone access d) Family support e) Marital status
a) Motivation for learning b) Health status c) Telephone access d) Family support Ideal candidates for home parenteral nutrition are patients who have a reasonable life expectancy after return home, have a limited number of illnesses other than the one that has resulted in the need for parenteral nutrition, and are highly motivated and fairly self-sufficient. Additional areas to consider include the patient's ability to learn, availability of family interest and support, adequate finances, and the physical plan of the home including access to water, electricity, refrigeration, and telephone. The patient's marital status is not important.
A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. The nurse does all of the following. Select all that apply. a) Places a 1.5-micron filter on the tubing b) Ensures availability of an infusion pump c) Ensures completion of baseline monitoring of the complete blood count (CBC) and chemistry panel d) Administers the intravenous antibiotic in the same tubing as the parenteral nutrtion e) Assesses for patency of the peripheral intravenous site
a) Places a 1.5-micron filter on the tubing b) Ensures availability of an infusion pump c) Ensures completion of baseline monitoring of the complete blood count (CBC) and chemistry panel Parenteral nutrition with dextrose concentrations of greater than 10% should not be administered through peripheral veins. An infusion pump should always be used for administration of parenteral nutrition. Standing orders are initiated that include monitoring of CBC and chemistry panel prior to the start of parenteral nutrition. Medications should not be administered in the same IV line as the parenteral nutrition because of potential incompatabilities with the components of the nutritional solution. A special filter (1.5-micron filter) is used with parenteral nutrition.
A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply. a) Remove gas and fluids from the stomach b) Evaluate for masses in the large colon c) Administer nutritional substances d) Diagnose gastrointestinal motility disorders e) Flush ingested toxins from the stomach
a) Remove gas and fluids from the stomach c) Administer nutritional substances d) Diagnose gastrointestinal motility disorders e) Flush ingested toxins from the stomach Gastrointestinal intubation is used to decompress the stomach and remove gas and fluids, lavage the stomach and remove ingested toxins or other harmful materials, diagnose disorders of GI motility, administer medications and feedings, compress a bleeding site, and aspirate gastric contents for analysis. Because gastrointestinal intubation involves the insertion of a tube into the stomach, beyond the pylorus into the duodenum or jejunum, it could not be used to evaluate for masses in the large colon.
The nurse is inserting a nasoenteric tube for a patient with a paralytic ileus. How long does the nurse anticipate the tube will be required? (Select all that apply.) a) Until bowel sound is present b) Until the patient stops vomiting c) Until flatus is passed d) Until the tube comes out on its own e) Until peristalsis is resumed
a) Until bowel sound is present c) Until flatus is passed e) Until peristalsis is resumed Before removing an enteral tube, the nurse may intermittently clamp it for a trial period of several hours to ensure that the patient does not experience nausea, vomiting, or distention. Before any tube is removed, it is flushed with 10 mL of water or normal saline to ensure that it is free of debris and away from the gastric lining. Gloves are worn when removing the tube. The tube is withdrawn gently and slowly for 15 to 20 cm (6 to 8 in) until the tip reaches the esophagus; the remainder is withdrawn rapidly from the nostril. If the tube does not come out easily, force should not be used, and the problem should be reported to the primary provider. As the tube is withdrawn, it is concealed in a towel to prevent secretions from soiling the patient or nurse. After the tube is removed, the nurse provides oral hygiene.
Intervention for a person who has swallowed strong acid includes a number of interventions depending on the type and amount of corrosive agent involved. Select all the actions that apply. a) Wash the esophagus with large volumes of water. b) Administer an irritant that will stimulate vomiting. c) Aspirate secretions from the pharynx if respirations are affected. d) Neutralize the chemical. e) Perform gastric lavage.
a) Wash the esophagus with large volumes of water. c) Aspirate secretions from the pharynx if respirations are affected. d) Neutralize the chemical. Vomiting and gastric lavage are contraindicated to avoid further injury.
The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly? a) Tape the tube to the head of the bed to avoid dislodgement. b) Keep the vent lumen above the patient's waist to prevent gastric content reflux. c) Maintain intermittent or continuous suction at a rate greater than 120 mm Hg. d) Irrigate only through the vent lumen.
b) Keep the vent lumen above the patient's waist to prevent gastric content reflux. The blue vent lumen should be kept above the patient's waist to prevent reflux of gastric contents through it; otherwise, it acts as a siphon.
A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. It is best for the nurse to a) Document the discontinuation of the nasogastric tube. b) Notify the surgeon about the tube's removal. c) Reinsert the nasogastric tube to the stomach. d) Place the nasogastric tube to the level of the esophagus.
b) Notify the surgeon about the tube's removal. If the nasogastric tube is removed accidently in a client who has undergone esophageal or gastric surgery, it is usually replaced by the physician. Care is taken to avoid trauma to the suture line. The nurse will not insert the tube to the esophagus or to the stomach in this situation. The nurse needs to do more than just document its removal. The nurse needs to notify the physician who will make a determination of leaving out or inserting a new nasogastric tube.
A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate? a) "It helps regulate the pressure on the suction machine." b) "It works as a marker to make sure that the tube stays in place." c) "It is a vent that prevents backflow of the secretions." d) "It acts as a siphon, pulling secretions into the clear tubing."
c) "It is a vent that prevents backflow of the secretions." The blue part of the Salem sump tube vents the larger suction-drainage tube to the atmosphere and, when kept above the patient's waist, prevents reflux of gastric contents through it. Otherwise it acts as a siphon. A gauge on the suction device regulates the pressure of the device. The tube has markings on it to aid in measurement.
A nurse is preparing to administer a 500 mL bolus tube feeding to a patient. The nurse anticipates administering this feeding over which time frame? a) 5 to 10 minutes b) 20 to 25 minutes c) 10 to 15 minutes d) 15 to 20 minutes
c) 10 to 15 minutes Typically a bolus tube feeding of 300 to 500 mL requires about 10 to 15 minutes to complete.
A client newly diagnosed with acute lymphocytic leukemia has a right subclavian central venous catheter in place. The nurse who's caring for the client is teaching a graduate nurse about central venous catheter care. The nurse should instruct the graduate nurse to change the central venous catheter dressing every: a) 72 hours. b) 24 hours. c) 48 hours. d) shift.
c) 48 hours. The nurse should instruct the graduate nurse to change the central venous catheter dressing every 48 hours or when the dressing becomes damaged or soiled.
A client who underwent abdominal surgery and has a nasogastric (NG) tube in place begins to complain of abdominal pain that he describes as "feeling full and uncomfortable." Which assessment should the nurse perform first? a) Auscultate bowel sounds. b) Assess vital signs. c) Assess patency of the NG tube. d) Measure abdominal girth.
c) Assess patency of the NG tube. When an NG tube is no longer patent, stomach contents collect in the stomach, giving the client a sensation of fullness. The nurse should begin by assessing patency of the NG tube. The nurse can measure abdominal girth, auscultate bowels, and assess vital signs, but she should check NG tube patency first to help relieve the client's discomfort.
The patient is on a continuous tube feeding. The tube placement should be checked every a) hour. b) 12 hours. c) shift. d) 24 hours.
c) shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding. Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities. Checking for placement every 12 or 24 hours does not meet the standard of care due the patient receiving continuous tube feedings.
A patient has had a gastrostomy tube inserted. What does the nurse anticipate the initial fluid nourishment will be after the insertion of the gastrostomy tube? a) High-calorie liquids b) Milk c) Distilled water d) 10% glucose and tap water
d) 10% glucose and tap water
A patient has had a gastrostomy tube inserted. What does the nurse anticipate the initial fluid nourishment will be after the insertion of the gastrostomy tube? a) High-calorie liquids b) Milk c) Distilled water d) 10% glucose and tap water
d) 10% glucose and tap water The first fluid nourishment is administered soon after tube insertion and can consist of a sterile water or normal saline flush of at least 30 mL. Tap water may be used during medication administration or tube feedings.
A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use? a) 20-mL b) 10-mL c) 5-mL d) 30-mL
d) 30-mL When small-bore feeding tubes for continuous tube feedings are used and irrigated after administration of medications, a 30-mL or larger syringe is necessary, because the pressure generated by smaller syringes could rupture the tube.
A patient is receiving a continuous tube feeding. The nurse notes that the feeding tube was last irrigated at 2 p.m. The nurse would plan to irrigate the tube again at which time? a) 4 p.m. to 6 p.m. b) 10 p.m. to 12 a.m. c) 8 p.m. to 10 p.m. d) 6 p.m. to 8 p.m.
d) 6 p.m. to 8 p.m. The recommendation is to irrigate the feeding tube of patients receiving continuous tube feedings every 4 to 6 hours. For this patient, the nurse would irrigate the tube next at 6 p.m. to 8 p.m.
A client is recovering from percutaneous endoscopic gastrostomy (PEG) tube placement. The nurse a) Maintains a gauze dressing over the site for 3 days b) Pushes the stabilizing disk firmly against the skin c) Immediately starts the prescribed tube feeding d) Administers an initial bolus of 50 mL water
d) Administers an initial bolus of 50 mL water The first fluid nourishment may consist of water, saline, or 10% dextrose. This may be administered as a bolus of 30 to 60 mL. By the second day, formula feeding may begin. A gauze dressing is applied between the tube insertion site and the gastrostomy tube. The dressing is changed daily or as needed. The nurse gently manipulates the stabilizing disk daily to prevent skin breakdown.
The client has just had a central line inserted for parenteral nutrition. The client is awaiting transport to the Radiology Department for catheter placement verification. The client reports feeling anxious. Respirations are 28 breaths/minute. The first action of the nurse is a) Position client flat in bed. b) Elevate the head of the bed. c) Consult with the healthcare provider. d) Auscultate lung sounds.
d) Auscultate lung sounds. Following placement of a central line, the client is at risk for a pneumothorax. The client's report of anxiety and increased respiratory rate may be the first signs and symptoms of a pneumothorax. The nurst first assesses the client by auscultating lung sounds. Other actions include placing the client in Fowler's position and consulting with the healthcare provider about findings.
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 a) Discard the residual volume b) Decrease the rate to 40 mL/hr c) Stop the continuous feeding d) Notify the physician
d) Notify the physician The second residual volume is greater than the first. When excessive residual volume (more than 200 mL) of a nasogastric feeding occurs twice, the nurse notifies the physician. The nurse does not discard the aspirate because the client has partially digested this fluid. After discussing with the physician, the nurse may stop the continuous feeding for some time or decrease the rate of infusion.
The nurse inserts a nasoduodenal tube for feeding of the client. To check best for placement, the nurse a) Auscultates when injecting air b) Adds 8 to 10 inches of the tube after inserting to the xiphoid process c) Aspirates contents and checks the color of the aspirate d) Verifies location with an abdominal x-ray
d) Verifies location with an abdominal x-ray Initially, an x-ray should be used to confirm placement of the nasoduodenal tube. It is the most accurate method to verify tube placement. Adding 8 to 10 inches to the length of the tube after measuring from nose to earlobe to xiphoid process is not supported, because it does not indicate that the tube will be in the correct position. Intestinal aspirate is usually clear and yellow to bile-colored. Gastric aspirate is usually cloudy and green, tan, off-white, or brown. Food particles may be present. The traditional method of injecting air through the tube while auscultating the epigastric area with a stethoscope to detect air insufflation is also an unreliable indicator.
Nursing students are reviewing information about various gastrointestinal tubes. They demonstrate a need for additional study when they identify which of the following as a nasogastric tube? a) Salem b) Dobbhoff c) Levin d) Sengstaken-Blakemore
b) Dobbhoff The Dobbhoff tube is a nasoenteric feeding tube. Levin, Salem, and Sengstaken-Blakemore tubes are nasogastric.
Hickman and Groshong are examples of which type of central venous access devices? a) Nontunneled central catheter b) Implanted ports c) Tunneled central catheters d) Peripherally inserted central catheters (PICC)
c) Tunneled central catheters Hickman and Groshong catheters are examples of tunneled central catheters. MediPort is an implanted port. A percutaneous subclavian Arrow is an example of a nontunneled central catheter. A PICC line is used for intermediate-term IV therapy for hospital, long-term care, or the home setting.
When preparing to insert a nasogastric tube, the nurse determines the length of the tube to be inserted. The nurse nurse places the distal tip of the tube at which location? a) Tragus of the ear b) Tip of the xiphoid process c) Base of the neck d) Tip of patient's nose
d) Tip of patient's nose To measure the length of the nasogastric tube, the nurse first places the distal tip of the tubing at the tip of the patient's nose, extends the tube to the tragus of the ear, and then extends the tube straight down to the tip of the xiphoid process.
The nurse is to insert a postpyloric feeding tube. One way that the nurse can aid in placement past the pylorus is to a) Assist the client to drink 8 ounces of water. b) Have the client lay on his left side. c) Instruct the client to swallow several times. d) Administer prescribed metoclopramide (Reglan).
d) Administer prescribed metoclopramide (Reglan). Metoclopramide (Reglan) is administered to increase peristalsis of the feeding tube into the duodenum. Placing the client on his right side, not the left side, helps to facilitate movement and placement. Having the client swallow or even to drink water facilitates placement of the tube past the epiglottis, not into the duodenum.
A patient is receiving a continuous tube feeding via an open delivery system. The patient is to receive 480 mL in 24 hours. The maximum amount of formula in the bag should not exceed which amount? a) 240 mL b) 80 mL c) 50 mL d) 120 mL
b) 80 mL When using an open delivery system, bacterial contamination is possible. Therefore, the amount of feeding formula in the bag should never exceed what should be infused in a 4-hour period. In this case that amount would be 80 mL. (480 mL divided by 24 hours equals 20 mL per hour. 20 mL times 4 hours equals 80 mL.)
A nurse suspects that a patient is developing rebound hypoglycemia secondary to parenteral nutrition being discontinued too rapidly. Which of the following would support the nurse's suspicions? Select all that apply. a) Tachycardia b) Reports of feeling flushed c) Shakiness d) Confusion e) Dry, hot skin f) Weakness
a) Tachycardia c) Shakiness d) Confusion f) Weakness Signs and symptoms of rebound hypoglycemia include weakness, faintness, sweating, shakiness, feeling cold, confusion, and increased heart rate.
Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the: a) Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. b) The patient cannot experience the deprivational stress of not swallowing. c) Digestive process occurs more rapidly as a result of the feedings not having to pass through the esophagus. d) Feedings can be administered with the patient in the recumbent position.
a) Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact. Regurgitation and aspiration are less likely to occur with a gastrostomy than with NG feedings.
A client is receiving a parenteral nutrition admixture that contains carbohydrates, electrolytes, vitamins, trace minerals, and sterile water and is now scheduled to receive an intravenous fat emulsion (Intralipid). The nurse a) Stops the admixture while the fat emulstion infuses b) Connects the tubing for the fat emulsion above the 1.5 micron filter c) Attaches the fat emulsion tubing to a Y connector close to the infusion site d) Starts a peripheral IV site to administer the fat emulsion
c) Attaches the fat emulsion tubing to a Y connector close to the infusion site An intravenous fat emulsion is attached to a Y connector close to the infusion site. The fat emulsion is administered simultaneously with the parenteral nutrition admixture. A separate peripheral IV site is not necessary. The fat emulsion is not administered through a filter.
When assisting with the plan of care for a client receiving tube feedings, which of the following would the nurse include to reduce the client's risk for aspiration? a) Keeping the client in a semi-Fowler's position at all times. b) Aspirating for residual contents every 4 to 8 hours. c) Giving the feedings at room temperature. d) Administering 15 to 30 mL of water every 4 hours.
a) Keeping the client in a semi-Fowler's position at all times. With continuous tube feedings, the nurse needs to keep the client in a semi-Fowler's position at all times to reduce regurgitation and the risk for aspiration. Aspirating for residual contents helps to ensure adequate nutrition and prevent overfeeding. Administering 15 to 30 mL of water every 4 hours helps to maintain tube patency. Giving the feedings at room temperature reduces the risk for diarrhea.
Which of the following medications requires the nurse to contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Soft gelatin capsules filled with liquid b) Enteric-coated tablets c) Buccal or sublingual tablets d) Simple compressed tablets
b) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change in the form of medication is necessary for patients with tube feedings. Simple compressed tablets may be crushed and dissolved in water for patients receiving oral medications by feeding tube. Buccal or sublingual tablets are absorbed by mucous membranes and may be given as intended to the patient undergoing tube feedings. The nurse may make an opening in the capsule and squeeze out contents for administration by feeding tube.
The nurse is inserting a sump tube in a patient with Crohn's disease who is suspected of having a bowel obstruction. What does the nurse understand is the benefit of the gastric (Salem) sump tube in comparison to some of the other tubes? a) The tube is radiopaque. b) The tube is shorter. c) The tube can be connected to suction and others cannot. d) The tube is less expensive.
a) The tube is radiopaque. The gastric (Salem) sump tube is a radiopaque (easily seen on x-ray), clear plastic, double-lumen nasogastric tube.
The nurse is to administer a cyclic feeding through a gastric tube. It is most important for the nurse to a) Elevate the head of the bed to 45 degrees. b) Change the tube feeding container and tubing. c) Accurately assess the amount of fluid infused. d) Check the residual volume before the feeding.
a) Elevate the head of the bed to 45 degrees. All the options are things that the nurse will do when administering a cyclic tube feeding. Elevating the head of the bed to 30 to 45 degrees assists in preventing aspiration into the lungs. This is a priority according to Maslow's hierarchy of needs.
If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first? a) Tell the client to take and hold a deep breath. b) Clamp the catheter. c) Call the physician. d) Apply a dry sterile dressing to the site.
b) Clamp the catheter. If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp. If a clamp isn't available, the nurse may place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension set and restart the infusion. Calling the physician, applying a dry sterile dressing to the site, and telling the client to take a deep breath aren't appropriate interventions at this time.
Rebound hypoglycemia is a complication of parenteral nutrition caused by which of the following? a) Fluid infusing rapidly b) Feedings stopped too abruptly c) Glucose intolerance d) Cap missing from the port
b) Feedings stopped too abruptly Rebound hypoglycemia occurs when the feedings are stopped too abruptly. Hyperglycemia is caused by glucose intolerance. Fluid overload is caused by fluids infusing too rapidly. An air embolism can occur from a cap missing on a port.
