Chapter 29: Prep U

The nurse is caring for a client who is receiving a standard, isotonic formula through a nasogastric tube. This formula is best suited to meet the client's nutritional needs if which client factor is present?

the client has normal digestion & absorption

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?

- dementia - stroke - removal of dentures

What is the nursing rationale for measuring the length of the external tube?

- reduces the risk of aspiration & bloating - helps prevent blockage

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

4 to 6 hrs

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

48 in (122 cm)

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

a radiographic exam that can confirm position

A nurse is preparing to administer an intermittent tube feeding to a client. The nurse checks the gastric residual and finds it to be 75 ml. What would the nurse do next?

administer the tube feeding

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

should remain with the head of the bed at least 30 degrees due to increased risk of gastric reflux related to the dilation of the cardiac sphincter

clients w/ nasogastric tubes

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

confirming the health care provider's order to remove the tube

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

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

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 prescriber has ordered assessment of the gastric residual volume of a client who is receiving enteral feedings. The nurse notes that there is a residual of 250 ml. Which action by the nurse is appropriate?

document the findings

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 mmol/l). What do these symptoms likely indicate?

dumping syndrom

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

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

should be no more than 100 mL or no more than 20% of the previous hour's tube-feeding volume

gastric residual volume

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

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

high-protein

Which is an appropriate intervention when unexpected situations occur during the administration of a tube feeding?

if the tube becomes clogged when aspirating contents, use warm water & gentle pressure to remove the clog

The nurse notices thick mucus that is obstructing the lumen of a client's nasogastric tube. What is the appropriate nursing action?

increase suction momentarily to clear the tubing

The nurse is caring for a client with a nasointestinal tube that has become blocked. The nurse attempts to flush the tube with 60 ml of warm water; however, this attempt is unsuccessful in unblocking the tube. What action will the nurse take next?

inform the health care provider

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 mmHg

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 degrees of client w/ a nasogastric feeding tube

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 the tube from the tip of the nose to the ear lobe & from the ear lobe to the xiphoid process

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

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

partially hydrolyzed

What is the nursing rationale for replacing all the gastric contents following measurement of aspirate?

preventing electrolyte imbalances

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

The nurse is slowly advancing a nasogastric tube when the client begins to gasp and is unable to vocalize. What action will the nurse take next?

remove the nasogastric tube & monitor the client

While assessing nasogastric tube placement prior to a feeding, the nurse assess the client's gastric contents. The pH is 6.2 and the apirate is off-white and tinged with mucus. Based on the findings, the nurse identifies that the tip of the nasogastric tubed is placed where?

respiratory tract

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

rotate the tube slightly & ask the client to swallow

A client requires gastric decompression. Which supply does the nurse anticipate gathering?

salem sump

The nurse has inserted a nasogastric tube for a client who requires enteral feeding. After completing tube insertion, what is the best method for the nurse to confirm tube placement prior to starting the feed?

send the client for an abdominal x-ray

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 & report the finding to the HCP

normal digestion & absorption =

standard isotonic for feeding tube

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 & assess for signs of respiratory distress

The nurse is caring for a client who has undergone abdominal surgery and has a history of dysphagia. A nasointestinal tube is in place for the client and a family member asks why this type of tube has been inserted. How will the nurse respond?

the client's condition places the client at a high risk for aspiration

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

What is the nursing rationale for elevating the head of the bed at least 30 degrees?

this facilitates the flow of feeding to the gut

What is the nursing rationale for confirming the pH of aspirate is less than 5.5?

this is useful in verifying correct placement!!!

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 of suction momentarily & reposition the client

The nurse is preparing to administer a client's tube feeding. How should the nurse position the client prior to beginning the infusion?

with the head of the bed at least 30 to 45 degrees