Prep u chapter 29

The nurse is flushing a client's feeding tube with 50 mL of water after giving medications through it. When the client asks, "Why are you doing that?" what is the appropriate nursing response?

"Water helps keep the feeding tube free from obstruction."

The nurse should include which action in the plan of care for the client receiving enteral feedings? Select all that apply.

-Check placement of the tube before initiating feeding. -Maintain the head of the bed elevated between 30 and 45 degrees for at least 30 minutes after feeding.

The client is NO and is prescribed tube feedings and placement of a nasointestinal feeding tube. What action(s) would the nurse perform in placement of the nasointestinal feeding tube? Select all that apply.

-Insert the tube with the stylet secured. -Aspirate fluid through the tube to test the pH. -Loop extra tubing prior to taping to the cheek.

A nurse is checking the placement of a nasogastric tube and aspirates fluid to test the pH. Which result would the nurse interpret as indicating that the tube is in the stomach?

3

A client who weighs 250 pounds (113 kg) is receiving nutrition via a feeding tube. How much daily hydration does the nurse calculate that the client needs?

3390 mL/day

A nurse administers a continuous tube feeding via an NG tube. The nurse must check for residual every:

4-6 hours

The nurse calculates the intake of a client who received a bolus tube feeding of 250 ml. The nurse administered 60 ml of water prior to the feeding and 60 ml of water after the feeding. The nurse administered crushed medications in 45 ml of water. Calculate the amount of fluid, in milliliters, the client received. Record your answer using a whole number.

415

A nurse is assisting a client with a Salem Sump tube. What is the standardized length of this device?

48 in (122 cm)

The nurse is preparing to insert a nasogastric tube into a client who is very anxious. Which nursing intervention is appropriate?

Agree upon a hand signal for when the client needs a pause.

The nurse should begin the process of removing a client's nasogastric (NG) tube by:

Confirming the physician's order to remove the tube.

A client is receiving enteral nutrition via an unvented nasogastric tube. Which suction settings will most likely prevent the tube from adhering to the wall of the client's stomach?

Intermittent suction at 40 to 60 mm Hg

A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which step should be performed as part of this procedure?

Measure tube from the tip of the nose to the ear lobe and from the ear lobe to the xiphoid process.

The nurse is preparing to place a nasogastric tube in a client. What is the process for determining the length of a nasogastric tube to be placed in the stomach?

Place distal tip to nose, then ear tip and end of xiphoid process.

The nurse is inserting a nasogastric tube and meets resistance with insertion. Which nursing action is most appropriate?

Rotate the tube slightly and ask the client to swallow.

The nurse is caring for a client who is receiving feedings through a nasogastric tube. The client has developed diarrhea. Which action will the nurse take first in response to this finding?

Slow the rate of the feed and report the finding to the health care provider.

The nurse is placing a nasogastric tube when the client becomes short of breath, coughs, and has difficulty breathing. What is the priority nursing action?

Stop placement and assess for signs of respiratory distress.

The nurse is checking placement of a nasogastric tube that has been in place for 2 days. The tube is draining green aspirate. What does this color of aspirate indicate?

The tube is in the stomach.

The nurse cares for a client with an endotracheal tube. Before each tube feeding, the nurse will check the tube placement and residual volume with the goal of preventing which priority concern?

To prevent aspiration

The nurse assesses that the drainage holes of a client's nasogastric tube are adhering to the gastric mucosal wall. What is the appropriate nursing action?

Turn off suction momentarily and reposition the client.

What is the most reliable method for verifying the correct placement of a nasogastric tube?

a radiographic exam that can confirm position

What is the pH of gastric aspirate?

acidic

The nurse is caring for an older adult client with Alzheimer disease. The client has just returned to the unit to begin supplemental tube feedings through a gastronomy tube. Which potential complication will be the nurse's priority?

aspiration

The nurse is caring for an older adult who is receiving tube feedings with a full-strength formula. Which priority diagnostic data does the nurse plan to review?

capillary blood glucose

A client is to start on continuous feedings via a weighted nasogastric tube. Which method should the nurse use to determine correct tube placement before starting the feedings?

bedside ultrasonography

The nurse is caring for a client with Parkinson disease who recently had a stroke and now requires a nasogastric tube for decompression. Which assessment finding does the nurse anticipate prior to inserting the tube?

depressed gag reflex

A nurse is obtaining the NEX measurement of a client before inserting a tube in the stomach. Which body part should the nurse measure to make the first mark on the tube?

distance from the nose to earlobe.

The nurse has just administered a high-carbohydrate bolus feed to a client through a nasointestinal feeding tube when the client reports gas, abdominal pain and dizziness. The nurse notes the client's blood glucose level is 60 mg/d (3.3 mol/I). What do these symptoms likely indicate?

dumping syndrome

A client with significant nutritional deficits is being placed on tube feedings. The client's condition indicates that he will need these feedings for a minimum of 6 to 8 weeks and possibly longer. The nurse would anticipate the use of which tube?

gastrostomy

Which type of feeding tube would be most appropriate for a client requiring enteral feeding for a long period of time?

gastrostomy tube

After measuring a nasogastric tube for insertion, the nurse marks the tube at the spot where the tube reaches the tip of the sternum. The nurse understands that this mark indicates the point at which the tube:

has reached the stomach.

A client with nonhealing wounds requires a feeding tube. Which type of formula does the nurse anticipate will be ordered?

high protein

While preparing clients for bedtime, the nurse finds the visiting family members affected the environment. Which action by a family member will make the nurse determine that the family needs additional teaching?

lowered head of bed to 15° of client with nasogastric feeding tube

The nurse is preparing a client who has been prescribed a nasogastric tube for insertion. Which measurement will the nurse take to effectively mark the tube?

nose to earlobe to xiphoid process

The nurse flushes a client's feeding tube after administering medications through it. What rationale does the nurse provide to the client for this action?

prevents tube obstruction

Nursing students are reviewing information about the advantages and disadvantages of the different types of feeding tubes. The students demonstrate understanding of the information when they identify which as an advantage of a nasointestinal feeding tube?

reduced danger for aspiration

A client with normal digestion and absorption requires a feeding tube. Which type of formula does the nurse anticipate will be ordered?

standard isotonic