A2 GI CH 39 Quizlet
Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding? 30 minutes 1 hour 90 minutes 2 hours
1 hour Explanation: The semi-Fowler position is necessary for a nasogastric (NG) feeding, with the client's head elevated at least 30 to 45 degrees to reduce the risk for reflux and pulmonary aspiration. This position is maintained for at least 1 hour after completion of an intermittent tube feeding and is maintained at all times for clients receiving continuous tube feedings.
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? 5 to 10 minutes 10 to 15 minutes 15 to 20 minutes 20 to 25 minutes
10 to 15 minutes Explanation: Typically a bolus tube feeding of 300 to 500 mL requires about 10 to 15 minutes to complete.
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying? Metoclopramide (Reglan) Famotidine (Pepcid) Nizatidine (Axid) Esomeprazole (Nexium)
Metoclopramide (Reglan) Explanation: Prokinetic agents which accelerate gastric emptying, used in the treatment of GERD, include bethanechol (Urecholine), domperidone (Motilium), and metoclopramide (Reglan). If reflux persists, the patient may be given antacids or H2 receptor antagonists, such as famotidine (Pepcid) or nizatidine (Axid). Proton pump inhibitors (medications that decrease the release of gastric acid, such as esomeprazole (Nexium) may be used, also.
The nurse cares for a client who receives continuous enteral tube feedings and who is at low risk for aspiration. The nurse assesses the gastric residual volume to be 350 mL. The nurse determines which action is correct? Monitoring the feeding closely. Increasing the feeding rate. Lowering the head of the bed. Flushing the feeding tube.
Monitoring the feeding closely. Explanation: High residual volumes (>200 mL) should alert the nurse to monitor the client more closely. Increasing the feeding rate will increase the residual volume. Lowering the head of the bed increases the client's risk for aspiration.
A patient has a gastric sump tube attached to low intermittent suction. The nurse empties the suction collection chamber and records an output of 320 mL for this 8-hour shift. The record shows that the tube had been irrigated with 20 mL of normal saline twice this shift. What would be the actual output of the gastric sump tube?
280 Explanation: The output measured includes the two 20 mL irrigations. To determine the actual output, the nurse would subtract the amount of irrigation used (in this case 40 mL total) from the total output (in this case 320 mL) and arrive at an output of 280 mL.
A client is recovering from percutaneous endoscopic gastrostomy (PEG) tube placement. The nurse Immediately starts the prescribed tube feeding Administers an initial bolus of 50 mL water Maintains a gauze dressing over the site for 3 days Pushes the stabilizing disk firmly against the skin
Administers an initial bolus of 50 mL water Explanation: 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.
Which of the following is a proton pump inhibitor used in the treatment of gastroesophageal reflux disease (GERD)? Select all that apply. Lansoprazole (Prevacid) Rabeprazole (AcipHex) Esomeprazole (Nexium) Famotidine (Pepcid) Nizatidine (Axid)
Lansoprazole (Prevacid) Rabeprazole (AcipHex) Esomeprazole (Nexium)
A nurse practitioner, who is treating a patient with GERD, knows that this type of drug helps treat the symptoms of the disease. The drug classification is: H2-receptor antagonists. Antispasmodics Proton pump inhibitors. Antacids
Proton pump inhibitors. Explanation: Proton pump inhibitors are the strongest inhibitors of acid secretions. The H2-receptor antagonists are the next most powerful.
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? 5-mL 10-mL 20-mL 30-mL
30-mL Explanation: 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.
Which of the following is the most common type of diverticulum? Zenker's diverticulum Mid-esophageal Epiphrenic Intramural
Zenker's diverticulum Explanation: The most common type of diverticulum, which is found three times more frequently in men than women, is Zenker's diverticulum (also known as pharyngoesophageal pulsion diverticulum or a pharyngeal pouch).
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? 4 p.m. to 6 p.m. 6 p.m. to 8 p.m. 8 p.m. to 10 p.m. 10 p.m. to 12 a.m.
6 p.m. to 8 p.m. Explanation: 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.
The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question? a low-fat diet elevation of upper body on pillows pantoprazole metoclopramide
metoclopramide Explanation: The instructions are appropriate for the client experiencing gastroesophageal reflux disease. The client is prescribed carbidopa/levodopa (Sinemet), which is used for Parkinson's disease. Metoclopramide can have extrapyramidal effects, and these effects can be increased in clients with Parkinson's disease.
A patient tells the nurse that it feels like food is "sticking" in the lower portion of the esophagus. What motility disorder does the nurse suspect these symptoms indicate? Achalasia Diffuse spasm Gastroesophageal reflex disease Hiatal hernia
Achalasia Explanation: Achalasia is absent or ineffective peristalsis of the distal esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing. Narrowing of the esophagus just above the stomach results in a gradually increasing dilation of the esophagus in the upper chest. The main symptom is difficulty in swallowing both liquids and solids. The patient has a sensation of food sticking in the lower portion of the esophagus.
The nurse is caring for a patient who has dumping syndrome from high-carbohydrate foods being administered over a period of fewer than 20 minutes. What is a nursing measure to prevent or minimize the dumping syndrome? Administer the feeding at a warm temperature to decrease peristalsis. Administer the feeding by bolus to prevent continuous intestinal distention. Administer the feeding with about 100 mL of fluid to dilute the high-carbohydrate concentration. Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time.
Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time. Explanation: The following strategies may help prevent some of the uncomfortable signs and symptoms of dumping syndrome related to tube feeding: 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. Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. Administer feedings at room temperature, not at a warm temperature, because temperature extremes stimulate peristalsis. Administer feeding by continuous drip (if tolerated), rather than by bolus, to prevent sudden distention of the intestine. Instill the minimal amount of water needed to flush the tubing before and after a feeding, not to dilute the formula but because fluid given with a feeding increases intestinal transit time.
Health teaching for a patient with GERD is directed toward decreasing lower esophageal sphincter pressure and irritation. The nurse instructs the patient to do which of the following? Select all that apply. Drink three, 8 oz. glasses of regular milk daily to coat the esophagus. Avoid beer, especially in the evening. Eat 1 hour before bedtime so there will be food in the stomach overnight to absorb excess acid. Elevate the head of the bed on 6- to 8-inch blocks. Elevate the upper body on pillows.
Avoid beer, especially in the evening. Elevate the head of the bed on 6- to 8-inch blocks. Elevate the upper body on pillows. Explanation: Milk should be avoided, as should eating before bed. Advise the patient not to eat or drink 2 hours before bedtime.
If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first? Call the physician. Apply a dry sterile dressing to the site. Clamp the catheter. Tell the client to take and hold a deep breath.
Clamp the catheter. Explanation: 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.
A nurse is caring for a client receiving parenteral nutrition at home. The client was discharged from the acute care facility 4 days ago. What would the nurse include in the client's plan of care? Select all that apply. Daily weights Intake and output monitoring Calorie counts for oral nutrients Daily transparent dressing changes Strict bedrest
Daily weights Intake and output monitoring Calorie counts for oral nutrients Explanation: For the client receiving parenteral nutrition at home, the nurse would obtain daily weights initially, decreasing them to two to three times per week once the client is stable. Intake and output monitoring also is necessary to evaluate fluid status. Calorie counts of oral nutrients are used to provide additional information about the client's nutritional status. Transparent dressings are changed weekly. Activity is encouraged based on the client's ability to maintain muscle tone. Strict bedrest is not appropriate.
The nurse is to administer a cyclic feeding through a gastric tube. It is most important for the nurse to Check the residual volume before the feeding. Accurately assess the amount of fluid infused. Elevate the head of the bed to 45 degrees. Change the tube feeding container and tubing.
Elevate the head of the bed to 45 degrees. Explanation: 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.
The nurse is caring for a comatose patient and administering gastrostomy feedings. What does the nurse understand is the reason that gastrostomy feedings are preferred to nasogastric (NG) feedings in the comatose patient? Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. Digestive process occurs more rapidly because the feedings do not have to pass through the esophagus. Feedings can be administered with the patient in the recumbent position. The patient cannot experience the deprivational stress of not swallowing.
Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. Explanation: Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely.
The nurse is caring for a client who has a gastrostomy tube feeding. Upon initiating care, the nurse aspirates the gastrotomy tube for gastric residual volume (GRV) and obtains 200 mL of gastric contents. What is the priority action by the nurse? Discontinue the infusion. Place the client in a semi-Fowler's position with the head of the bed at 45 degrees. Remove the aspirated fluid and do not reinstill. Dilute the gastric tube feeding solution with water and continue the feeding.
Place the client in a semi-Fowler's position with the head of the bed at 45 degrees. Explanation: Feedings and medications should always be administered with the client in the semi-Fowler's position, and the client's head should be elevated at least 30 to 45 degrees to reduce the risk of reflux and pulmonary aspiration. This position is maintained at least 1 hour after completion of an intermittent tube feeding and is maintained at all times for clients receiving continuous tube feedings.
A client has been diagnosed with achalasia based on his history and diagnostic imaging results. The nurse should identify what risk diagnosis when planning the client's care? Risk for Aspiration Related to Inhalation of Gastric Contents Risk for Imbalanced Nutrition: Less than Body Requirements Related to Impaired Absorption Risk for Decreased Cardiac Output Related to Vasovagal Response Risk for Impaired Verbal Communication Related to Oral Trauma
Risk for Aspiration Related to Inhalation of Gastric Contents Explanation: Achalasia can result in the aspiration of gastric contents. It is not normally an acute risk to the client's nutritional status and does not affect cardiac output or communication.
The healthcare provider of a client with oral cancer has ordered the placement of a GI tube to provide nutrition and to deliver medications. What would be the preferred route? nasogastric intubation orogastric intubation nasoenteric intubation gastrostomy
nasogastric intubation Explanation: The nasal route is the preferred route for passing a tube when the client's nose is intact and free from injury.
A client has been diagnosed with Zenker's diverticulum. What treatment does the nurse include in the client education? A low-residue diet Chemotherapeutic agents Radiation therapy Surgical removal of the diverticulum
Surgical removal of the diverticulum Explanation: Because Zenker's diverticulum is progressive, the only means of cure is surgical removal of the diverticulum. A low-residue diet will not stop the progression of the disease. Chemotherapy and radiation therapy will not target the specific site of the Zenker's diverticulum.
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.) Until bowel sound is present Until flatus is passed Until peristalsis is resumed Until the patient stops vomiting Until the tube comes out on its own
Until bowel sound is present Until flatus is passed Until peristalsis is resumed Explanation: 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.
Prior to a client's scheduled jejunostomy, the nurse is performing the preoperative assessment. What goal should the nurse prioritize during the preoperative assessment? Determining the client's nutritional needs Determining that the client fully understands the postoperative care required Determining the client's ability to understand and cooperate with the procedure Determining the client's ability to cope with an altered body image
Determining the client's ability to understand and cooperate with the procedure Explanation: The major focus of the preoperative assessment is to determine the client's ability both to understand and cooperate with the procedure. Body image, nutritional needs, and postoperative care are all important variables, but they are not the main focuses of assessment during the immediate preoperative period.
The nurse is teaching a client with gastroesophageal reflux disease (GERD) about how to reduce reflux. What should the nurse include in the teaching? Select all that apply. Encourage the client to eat frequent, small, well-balanced meals. Inform the client to remain upright for at least 2 hours after meals. Encourage the client to eat later in the day before bedtime rather than early in the morning. Instruct the client to avoid alcohol or tobacco products. Instruct the client to eat slowly and chew the food thoroughly.
Encourage the client to eat frequent, small, well-balanced meals. Inform the client to remain upright for at least 2 hours after meals. Instruct the client to avoid alcohol or tobacco products. Instruct the client to eat slowly and chew the food thoroughly. Explanation: The nurse should encourage the client to eat frequent, small, well-balanced meals, inform the client to remain upright for at least 2 hours after meals, instruct the client to avoid alcohol or tobacco products, and instruct the client to eat slowly and chew the food thoroughly when teaching the client how to reduce reflux. The nurse should discourage the client from eating before bedtime.
A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely? Excess fluid volume Risk for imbalanced nutrition, more than body requirements Deficient fluid volume Impaired urinary elimination
Excess fluid volume Explanation: The patient's intake and output record reflects a greater intake than output, suggesting excess fluid volume. No information suggests that the patient's nutritional balance is at risk, even with nasogastric tube feedings. Deficient fluid volume would be appropriate if the patient's output exceeded input. No information indicates that the patient is experiencing difficulty with urination.
A client has a new order for metoclopramide. What potential side effects should the nurse educate the client about? Extrapyramidal Peptic ulcer disease Gastric slowing Nausea
Extrapyramidal (impaired motor control) Explanation: Metoclopramide (Reglan) is a prokinetic agent that accelerates gastric emptying. Because metoclopramide can have extrapyramidal side effects that are increased in certain neuromuscular disorders, such as Parkinson's disease, it should be used only if no other option exists, and the client should be monitored closely. It is contraindicated with hemorrhage or perforation. It is not used to treat gastritis.
The nurse is caring for a client receiving enteral nutrition with a standard polymeric formula. For which reason will the nurse question using this formula for the client? History of diverticulitis Treatment for internal hemorrhoids Polyps removed during a colonoscopy Diagnosed with malabsorption syndrome
Diagnosed with malabsorption syndrome Explanation: Various tube feeding formulas are available commercially. Polymeric formulas are the most common and are composed of protein (10% to 15%), carbohydrates (50% to 60%), and fats (30% to 35%). Standard polymeric formulas are undigested and require that the client has relatively normal digestive function and absorptive capacity. This type of formula should be questioned because the client is diagnosed with malabsorption syndrome. There is no reason to question the client for a history of diverticulitis, treatment for internal hemorrhoids, or removal of polyps.
When assessing whether a client is a candidate for home parenteral nutrition, what would be important to address? Select all that apply. Family support Telephone access Marital status Motivation for learning Health status
Family support Telephone access Motivation for learning Health status Explanation: 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 client'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 client's marital status is not important.
A client with a diagnosis of late-stage Alzheimer disease has begun supplemental feedings through a nasogastric (NG) tube. Which of the nurse's assessments addresses this client's most significant potential complication of feeding? Frequent assessment of the client's abdominal girth Assessment for hemorrhage from the nasal insertion site Frequent lung auscultation Frequent monitoring of the frequency and character of bowel movements
Frequent lung auscultation Explanation: Aspiration is a risk associated with tube feeding; this risk may be exacerbated by the client's cognitive deficits. Consequently, the nurse should auscultate the client's lungs and monitor oxygen saturation closely. Bowel function is important, but the risk for aspiration is a priority. Hemorrhage is highly unlikely and the client's abdominal girth is not a main focus of assessment.
A client who has recovered from anesthesia following oral surgery for lip cancer is experiencing difficulty breathing deeply and coughing up secretions. Which of the following measures will help ease the client's discomfort? Keeping the head of the bed elevated. Positioning the client flat on the abdomen or side. Providing a tracheostomy tray near the bed. Turning the client's head to the side.
Keeping the head of the bed elevated. Explanation: It is essential to position the client with the head of the bed elevated because it is easier for the client to breathe deeply and cough up secretions after recovering from the anesthetic. Positioning the client flat either on the abdomen or side with the head turned to the side will facilitate drainage from the mouth. A tracheostomy tray is kept by the bed for respiratory distress or airway obstruction. When mouth irrigation is carried out, the nurse should turn the client's head to the side to allow the solution to run in gently and flow out.
The health care provider orders the insertion of a single lumen nasogastric tube. When gathering the equipment for the insertion, what will the nurse select? Salem sump tube Miller-Abbott tube Sengstaken-Blakemore tube Levin tube
Levin tube Explanation: A Levin tube is a single lumen nasogastric tube. A Salem sump tube is a double lumen nasogastric tube; a Sengstaken-Blakemore tube is a triple lumen nasogastric tube. A Miller-Abbott tube is a double lumen nasoenteric tube.