Chapter 29: Gastrointestinal Intubation
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."
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
The nurse has assessed 500 mL of gastric residual for a client. What is the initial nursing action?
Hold the next scheduled feeding.
Which is the best noninvasive means of unclogging tubes?
pancreatic enzymes and water
What is the Levin tube and how is it used to treat a client?
tube connected to low intermittent suction to avoid erosion or tearing of the stomach lining
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 nursing instructor is talking about caring for patients with feeding tubes and endotracheal tubes (ET). The instructor tells the students that before each tube feeding, the nurse should check for tube placement in the stomach as well as residual volume. What is the purpose of the nurse's actions?
Prevent aspiration.
The nurse is caring for a client with a nasogastric tube that is draining poorly. Upon assessment, the nurse notices that the tube is displaced above the esophageal sphincter. What is the appropriate nursing action?
Remove the tape, advance the tube and then check placement.
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.
A client requires gastric decompression. Which supply does the nurse anticipate gathering?
Salem Sump
A nurse is preparing to remove an intestinal decompression tube. Which nursing action is most appropriate?
Withdraw 10 inches of the tube and then wait 10 minutes.
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.
The nurse is caring for an elderly client with Alzheimer disease. The client has just returned to the unit to begin supplemental tube feedings through a gastrostomy tube. The nurse should be most concerned with the potential for:
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 who has been receiving tube feedings is beginning to take in oral food and fluids. To facilitate weaning the client from tube feedings, which delivery method does the nurse anticipate?
cyclic feedings
The nurse is caring for a client with Parkinson's 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
The nurse is caring for a client who has had excessive diarrhea and now requires tube feeding. Which type of formula does the nurse anticipate will be ordered?
fiber containing
The nurse is caring for a client with excessive diarrhea who requires tube feeding. Which type of formula does the nurse anticipate will be ordered?
fiber containing
A nurse is assessing a client with a stomach ache before inserting a nasogastric tube. Which client aspects should the nurse assess before inserting a nasogastric tube? Select all that apply.
weight oral mucosa bowel sounds
Which is an accurate step when removing a nasogastric tube?
Before removing the tube, discontinue suction and separate the tube from suction.
The nurse has assessed that a client's nasogastric tube is obstructed. What is the appropriate nursing action?
Contact the health care provider
What is the pH of gastric aspirate?
acidic
A nurse caring for a client with a nasogastric tube knows that the best way to check correct placement of the tube is:
assessment of color of aspirate and laboratory testing of the aspirate.
The nurse is caring for a client with impaired swallowing who requires tube feeding. Which type of formula does the nurse anticipate will be ordered?
standard isotonic
The nurse has completed discharge teaching for a client who will continue tube feeding at home. Which client statement requires further nursing teaching?
"Ensure® and BOOST® products can help me gain additional calories needed."
The nurse is providing discharge teaching for a client who will continue to administer tube feedings at home. The client states, "I don't think I can do this." What is the appropriate nursing response?
"Perhaps we can contact a home health nurse to assist."
The nurse is preparing to check gastric residual for a client who had a tube feeding. After stopping the infusion of the tube-feeding formula, what is the nurse's next action?
Aspirate fluid from the feeding tube.
The nurse is caring for an older adult client with dementia who continues to pull at a nasogastric feeding tube. What is the appropriate initial nursing action?
Attempt to divert client's attention from tube.
The nurse is initiating a continuous feeding for a client who has been admitted to the medical-surgical nursing unit. At what rate will the nurse set the rate of administration?
1.5 mL/min
A client who weighs 175 pounds (79 kg) is receiving nutrition via a feeding tube. How much daily hydration does the nurse calculate that the client needs?
2370 mL/day
A client is receiving a continuous tube feeding using a commercially prepared formula at home. The nurse would instruct the client's caregiver to use the formula within which time frame once the container is opened?
24 hours
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 client has a Salem sump tube inserted for gastric decompression. The physician orders the tube to be attached to low intermittent suction. The nurse attaches the tube to the wall suction unit. Which setting would be appropriate?
45 mm Hg
A nurse is assisting a client with a Salem sump tube. How many inches is the length of this device? Record your answer using a whole number.
48
Which method may the nurse use to confirm placement of a nasogastric tube? (Select all that apply.)
Obtain an x-ray with the order of a physician. Aspirate fluid and test the pH. Insert air while auscultating the patient's abdomen.
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.
A client who is receiving tube feedings has developed diarrhea. Which nursing intervention is appropriate?
Consult with the health care provider about using a milk-free formula.
The nurse is teaching an older adult client how to administer tube feedings at home. Despite several interventions, the client cannot provide a return demonstration. Which nursing action is appropriate?
Contact home health services for a home health nurse.
Upon assessing that a client's nasogastric tube is obstructed, what is the appropriate nursing action?
Contact the health care provider.
A nurse is caring for an older adult client with diminished efficiency of the gag reflexes. Which factors contribute to lowered efficiency of the gag reflexes? Select all that apply.
Dementia Stroke Removal of dentures
A client with a nasogastric tube inserted for gastric decompression now has an order for the tube to be removed. The nurse has placed the client in a sitting position, covered the chest with a clean towel, placed the emesis basin and tissues within reach, and removed the tape securing the tube. The nurse then puts on clean gloves and is about to continue. Place the steps in the order that the nurse would complete them, from first to last.
Disconnect the tube after turning off the suction. Instill a bolus of air into the draining lumen. Pinch off the tube. Instruct the client to take and hold a deep breath. Remove the tube from the client's nose gently and slowly. Enclose the tube within the glove for discarding.
Nursing students are reviewing information about the types of gastrointestinal tubes. The students demonstrate understanding of the information when they identify which tube as a single-lumen tube? Select all that apply.
Ewald Levin
The nurse has assessed 100 mL of gastric residual after completing a tube feeding. What is the appropriate nursing action?
Document the assessment finding.
The nurse has assessed 50 mL of gastric residual after completing a tube feeding. What is the appropriate nursing action?
Document the assessment finding.
The nurse is assessing the gastric residual volume of a client receiving enteral feedings. The nurse notes there is a residual of 250 cc. Which action by the nurse is most appropriate?
Document the findings.
A client is receiving intermittent tube feedings six times a day. Which would the nurse need to do after each feeding?
Flush the solution container thoroughly.
During a tube feeding, the nurse visualizes aspirated contents, checking for color and consistency. What are normal findings? (Select all that apply.)
Gastric fluid can be green with particles, off-white, or brown if old blood is present. Intestinal aspirate tends to look clear or straw-colored to a deep golden-yellow color. Respiratory or tracheobronchial fluid is usually off-white to tan.
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
Mercury is typically used in the placement of which tubes?
Miller-Abbott
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.
A nurse has washed her hands and donned gloves to prepare for checking the gastric residual for a client. Place the steps in this skill in the correct sequence from first to last.
Stop the infusion of the tube-feeding formula. Aspirate fluid from the feeding tube using a 50-mL syringe. Continue aspirating until no more fluid is obtained. Measure the aspirated fluid and record the amount. Reinstill the aspirated fluid. Postpone tube feeding and report residual amounts that exceed agency guidelines or those established by the physician. Check gastric residual again in 30 minutes and provide or resume tube feeding if range is acceptable.
A client receiving tube feedings has a gastric residual of 500 mL. Which nursing intervention is most appropriate?
Stop the infusion.
The nurse is assessing the pH of gastric residual on a client with nasogastric tube. The pH level is 7. What is the most appropriate nursing response?
The nurse suspects that the tube is in the small intestine.
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.
A client with fluid restriction requires a feeding tube. Which type of formula does the nurse anticipate will be ordered?
high calorie
A client with non-healing wounds requires a feeding tube. Which type of formula does the nurse anticipate will be ordered?
high protein
Which type of tube feeding involves insertion of the tube through the nose into the stomach?
nasogastric
A client with continuous vomiting requires gastrointestinal intubation. Which tube does the nurse anticipate inserting for gastric decompression?
nasogastric sump tube
Which feeding tube might a physician prescribe to rest the client's bowel following surgery to remove a tumor?
nasogastric 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
A client who overdosed by taking a bottle of acetaminophen has been brought to the emergency department. The nurse gathers which tube that will be used to remove the toxic substance that has been ingested?
orogastric
The nurse is caring for a client who has Crohn's disease with impaired absorption and now requires tube feeding. Which type of formula does the nurse anticipate will be ordered?
partially hydrolyzed
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
A 71-year-old woman has presented to the emergency department with intense abdominal pain accompanied by nausea and vomiting. Diagnostic imaging results indicate that the client has a bowel obstruction and the emergency physician has ordered the insertion of a nasogastric tube. What is the most likely rationale for the client's gastrointestinal intubation?
promoting decompression
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 diarrhea requires a feeding tube. Which type of formula does the nurse anticipate will be ordered?
standard isotonic
A client with normal digestion and absorption requires a feeding tube. Which type of formula does the nurse anticipate will be ordered?
standard isotonic
The nurse is caring for a client who is unable to swallow due to a recent stroke. This client has a newly placed feeding tube. Which type of formula does the nurse anticipate will be ordered?
standard isotonic