NCLEX: Gastrointestinal

3 (Rationale: All the stomach contents are aspirated and measured before administering a tube feeding. This procedure measures the gastric residual volume. The gastric residual volume is checked to confirm whether undigested formula from a previous feeding remains and thereby evaluates the absorption of the last feeding. It is important to check the gastric residual before administration of a tube feeding. A full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration. If residual feeding is obtained, the health care provider's prescription and agency policy are checked to determine the course of action hold or reduce the volume of the intermittent tube feeding.)

Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. Which is the best rationale for checking gastric residual volume before administering the tube feeding? 1. Observe the digestion of formula. 2. Check fluid and electrolyte status. 3. Evaluate absorption of the last feeding. 4. Confirm proper nasogastric tube placement.

Circular

Clean ostomy in this motion with warm soapy washcloth and expect some bleeding, pat dry

Salem sump

Double-lumen NG tube with air vent used for decompression with intermittent continuous suction

1/2 to 1/3

Empty ostomy bag when it is

NPO, 6-8 hours prior

GI study prep=

3-4

How many inches should the ng tube be lubricated

10

How many ml to aspirate

30

How many ml to check patency

60

How many ml to flush

Dehiscence

Incision is open

Yellowness of skin, sclera, mucous membrane, and body fluid (poc= mucous membrane in mouth and palms of hands)

Jaundice=

3-4

Ng tube gastric contents pH should be

Descending and sigmoidostomy

Only two ostomies that can be regulated by diet and irrigations

Enterocele

Pelvic contents protrude into vagina and rectum

Rectocele

Rectum protrudes into the vagina

Levin

Single-lumen NG tube used to remove gastric contents via intermittent suction or to provide tube feedings

Ilieostomy

Stool is always liquid in

1 (Rationale: A Sengstaken-Blakemore tube is inserted in a client with a diagnosis of cirrhosis with ruptured esophageal varices when other measures used to treat the varices are unsuccessful or contraindicated for the client. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices, noted by hematemesis.)

The nurse has been caring for a client with a Sengstaken-Blakemore tube. The health care provider arrives on the nursing unit and deflates the esophageal balloon. Following deflation of the balloon, the nurse should monitor the client closely for which? 1. Hematemesis 2. Bloody diarrhea 3. Swelling of the abdomen 4. An elevated temperature and a rise in blood pressure

1 (Rationale: If the NG tube is in the stomach, the pH of the contents will be acidic. Options 2 and 3 indicate a slightly acidic pH. Option 4 indicates a neutral pH.)

The nurse is checking a client for the correct placement of a nasogastric (NG) tube. The nurse aspirates the client's stomach contents and checks its pH level. Which pH value indicates the correct placement of the tube? 1. 3.5 2. 4.5 3. 6.0 4. 7.35

3 (Rationale: A Sengstaken-Blakemore tube is inserted via the nose into the esophagus and stomach. The other options are incorrect because this tube is not inserted in those manners.)

Treatment measures have been implemented for a client with bleeding esophageal varices and have been unsuccessful. The health care provider states that a Sengstaken-Blakemore tube will be used to control the resulting hemorrhage. The nurse prepares for insertion via which route? 1. Percutaneous 2. Oral-gastric 3. Nasogastric 4. Gastrostomy

Supine

What position should abd girth be measured in

Cystocele

Where bladder protrudes into the vagina

4 (Rationale: A Sengstaken-Blakemore tube is inserted in cirrhotic clients with ruptured esophageal varices when other measures are ineffective. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to the esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the exiting esophageal varices.)

After the deflation of the balloon of a client's Sengstaken-Blakemore tube, the nurse monitors the client closely for which esophageal complication? 1. Varices 2. Necrosis 3. Rupture 4. Hemorrhage

1 (Rationale: A decrease in sour eructation (burping) represents a change in the client's health status and is an effective indicator of a successful outcome. Options 2 and 3 are not consistent with minimizing disease symptoms. Option 4 represents healthy behavior by the client, but it is not as positive as is the correct option.)

The nurse has been reinforcing dietary teaching for a client with gastroesophageal reflux disease (GERD) who has a routine follow-up visit. Which behavior is the best indicator of a successful outcome for this client? 1. A decrease in sour eructation 2. Taking in increased dairy products 3. Use of only decaffeinated coffee and tea 4. Decreased use of as-needed (PRN) medications

4 (Rationale: After the nasogastric tube is in place, mouth care is extremely important. With one naris occluded, the client tends to mouth breathe, drying the mucous membranes. Frequent oral hygiene may be required to prevent or care for dry, irritated mucous membranes. Frequent, small sips of water would be contraindicated when the client is on gastric suction. The hard candy would increase the salivation but would not be useful in cleaning the oral cavity. Lemon glycerin swabs have a drying or irritating effect on the mucous membranes.)

The nurse observes that a client with a nasogastric tube connected to continuous gastric suction is mouth breathing, has dry mucous membranes, and has a foul breath odor. In planning care, which nursing intervention would be best to maintain the integrity of this client's oral mucosa? 1. Offer small sips of water frequently. 2. Encourage the client to suck on sour, hard candy. 3. Use lemon glycerin swabs to provide oral hygiene. 4. Use diluted mouthwash and water to rinse the mouth after brushing teeth.

2 (Rationale: The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine (to correct a bowel obstruction). The end of the tube should be located in the intestine. The pH of the gastric fluid is acidic, and the pH of the intestinal fluid is 7 or higher if the tube is adequately located. Location of the tube can also be determined by x-ray, not palpation. Options 1 and 3 are incorrect and would not determine adequate location of the tube.)

A client had a Miller-Abbott tube inserted 24 hours ago. The nurse is asked to check the client to determine whether the tube is in the appropriate location at this time. Which finding would indicate adequate location of the tube? 1. Bowel sounds are absent. 2. The aspirate from the tube has a pH of 7.45. 3. The aspirate from the tube has a pH of 6.5. 4. The tube can be palpated to the right of the umbilicus.

3 (Rationale: During the insertion of a nasogastric tube, the client is placed in a sitting or high-Fowler's position to reduce the risk of pulmonary aspiration if the client should vomit. Options 1, 2, and 4 do not facilitate the insertion of the tube or prevent aspiration.)

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1. Right side 2. Low-Fowler's position 3. High-Fowler's position 4. Supine, with the head flat

4 (Rationale: A Salem Sump tube is used commonly for gastric intubation and has a larger suction lumen and an air vent. Option 1 describes a Levin tube. Option 2 describes a tube used for small intestinal feedings. Option 3 describes a tube used for gastroesophageal bleeding.)

A health care provider asks the nurse to obtain a Salem Sump tube for gastric intubation. The nurse should correctly select which tube from the unit storage area? 1. A nasogastric tube 2. A jeujunostomy tube 3. A Sengstaken-Blakemore tube 4. A tube with a larger lumen and an air vent

3 (Rationale: The Miller-Abbott tube is a nasoenteric tube, which is used to decompress the intestine and correct a bowel obstruction. Initial insertion of the tube is a health care provider's responsibility. The tube is weighted by a special substance and either advances by gravity or may be advanced manually. Advancement of the tube can be monitored by measuring the tube and by taking serial x-rays. Options 1, 2, and 4 are incorrect nursing actions. The nurse would, however, keep the registered nurse informed about the progress of the tube advancement.)

A health care provider places a Miller-Abbott tube in a client who has a bowel obstruction. Six hours later, the nurse measures the length of the tube outside of the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action should the nurse take next? 1. Initiate a tube feeding. 2. Notify the health care provider. 3. Document the finding in the client's record. 4. Pull the tube out 6 cm, and secure the tube to the nose with tape.

3 (Rationale: When the NG tube is removed, the client is instructed to take and hold a deep breath. This will close the epiglottis, and the airway will be temporarily obstructed during the tube removal. This allows for the easy withdrawal of the tube through the esophagus into the nose. The tube is removed with one very smooth, continuous pull. Options 1, 2, and 4 are incorrect.)

A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. The LPN should reinforce instructing the client to perform which action? 1. Exhale. 2. Inhale and exhale quickly. 3. Take and hold a deep breath. 4. Perform Valsalva's maneuver.

1, 2, 3, 5 (Rationale: The most common symptoms of GERD include heartburn sometimes described as chest pain, regurgitation, trouble swallowing, sore throat, and nausea. GERD pain is sometimes described as epigastric pain not abdominal pain. It does not cause bloody stool.)

A patient is seen in the clinic for symptoms consistent with gastroesophageal reflux disease. The nurse should expect which common symptoms? Select all that apply. 1. Nausea 2. Sore throat 3. Regurgitation 4. Bloody stool 5. Epigastric pain 6. Abdominal pain

2 (Rationale: The nurse places highest priority on managing the client's airway. This includes assessing for return of the gag reflex. The client's vital signs are also monitored, and a sudden sharp increase in temperature could indicate perforation of the GI tract. This should be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client's airway still takes priority.)

A client has undergone esophagogastroduodenoscopy (EGD). The nurse places highest priority on which action as part of the client's care plan? 1. Monitoring the temperature 2. Checking for return of a gag reflex 3. Giving warm gargles for a sore throat 4. Monitoring for complaints of heartburn

2 (Rationale: After the nurse inserts a nasogastric tube into a client, the correct location of the tube must be verified. The nurse follows the approved procedure for inserting a nasogastric tube, including correct measurement and aspirating fluid with the visible characteristics of gastric fluid. The presence of blood (option 3) is unrelated to the location of the tube. Aspirate is dark green, and the tube is inserted the length measuring from the client's ear to nose and nose to xiphoid process. However, testing the pH of the gastric fluid and determining its acidity is the most reliable verification that the tube is correctly placed.)

The nurse is caring for a client with a nasogastric tube. Which observation is most reliable in determining that the tube is correctly placed? 1. The aspirate is dark green. 2. The pH of the aspirate is 5. 3. The aspirate is negative for guaiac. 4. The tube is inserted the length measured from the client's ear to nose and nose to xiphoid process.

4 (Rationale: A prolapsed stoma is one in which bowel protrudes through the stoma, with an elongated and swollen appearance. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with dusky or bluish color. A stoma with a narrowed opening, either at the level of the skin or fascia, is said to be stenosed.)

The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred? 1. Dark and bluish 2. Sunken and hidden 3. Narrowed and flattened 4. Protruding and swollen

2 (Rationale: A Sengstaken-Blakemore tube is inserted in a client with a diagnosis of cirrhosis with ruptured esophageal varices when other measures used to treat the varices are unsuccessful or contraindicated for the client. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could harm the client. This tube is not used to treat the conditions noted in the remaining options.)

The nurse is assigned to care for a client who had a Sengstaken-Blakemore tube inserted when more conservative treatment failed to alleviate the condition. The nurse should suspect that the client has which diagnosis? 1. Gastritis 2. Esophageal varices 3. Bowel obstruction 4. Small bowel tumor

1 (Rationale: Feeding can be hung at room temperature for a period of 4 hours. If 100 mL/hr is prescribed, the nurse should fill the feeding bag with a maximum amount of 400 mL. Feeding hung longer than 4 hours at room temperature creates the risk of bacterial invasion in the formula.)

The nurse is preparing to administer a continuous tube feeding to a client with a nasogastric tube. The health care provider has prescribed an amount of 100 mL/hr. How much formula should the nurse plan to add to fill the feeding bag? 1. 400 mL of formula 2. 600 mL of formula 3. 800 mL of formula 4. Enough formula to last for 8 hours

3 (Rationale: Unless otherwise instructed or if the residual contents appear abnormal, an amount of less than 100 mL may be reinstituted; then a normal amount of prescribed tube feeding is administered. It is important to return the contents to the stomach to prevent electrolyte imbalances. Therefore, options 1, 2, and 4 are incorrect.)

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do with the aspirated residual? 1. Hold the feeding. 2. Place it into a container for laboratory analysis. 3. Reinstill the residual and administer the feeding. 4. Deduct the amount of the residual from the new feeding and administer that amount to the client.

2 (Rationale: The nurse needs to recognize that the client has a greater need for security and acceptance than education. In option 2, the nurse conveys acceptance of the client and uses the therapeutic communication technique of silence. Options 1, 3, and 4 block communication and do not address the client's need.)

A client is admitted to the hospital with a bowel obstruction secondary to a recurrent malignancy, and the health care provider plans to insert a Miller-Abbott tube. When the nurse tries to explain the procedure, the client interrupts the nurse and states, "I don't want to hear about that. Just let the doctor do it." Based on the client's statement, which is the nurse's best action? 1. Leave the room. 2. Remain with the client and be silent. 3. Ask the client whether he would like another nurse to care for him. 4. Explain to the client that all clients have the right to know about medical procedures.