Chapter 39
A nurse is caring for a client with a long-term central venous catheter. Which care principle is correct?
Clean the port with an alcohol pad before administering I.V. fluid through the catheter.
A nurse providing care to a patient who is receiving nasogastric tube feedings finds that the tube is clogged. Which of the following is no longer considered appropriate to use to unclog the tube?
Cranberry juice
The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take?
Flush with 10 mL of water.
A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition?
Gastroesophageal reflux disease
A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate?
Gastroesophageal reflux disease
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.
When preparing to insert a nasogastric tube, the nurse determines the length of the tube to be inserted. The nurse places the distal tip of the tube at which location?
Tip of patient's nose
The nurse is caring for a client receiving a tube feeding. Which assessments will the nurse prioritize for this client? Select all that apply.
Body weight Blood glucose level Signs of dehydration Placement of the tube
Which clinical manifestation is not associated with hemorrhage?
Bradycardia
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
Residual content is checked before each intermittent tube feeding. The patient would be reassessed if the residual, on two occasions, was:
Greater than 200 mL.
A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse?
Notify the surgeon about the tube's removal.
The nurse teaches an unlicensed caregiver about bathing clients who are receiving tube feedings. The most significant complication related to continuous tube feedings is the
potential risk for aspiration.
The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every
shift
As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach?
4
Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the:
Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration.
The primary source of microorganisms for catheter-related infections are the skin and which of the following?
Catheter hub
If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?
Clamp the catheter.
A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for?
diaphoresis, vomiting, and diarrhea.
A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to
Auscultate lung sounds every 4 hours.
The school nurse is planning a health fair for a group elementary school students and dental health is one topic that the nurse plans to address. When teaching the children about the risk of tooth decay, the nurse should caution them against consuming large quantities of
organic fruit juice.
A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an):
Protrusion of the upper stomach into the lower portion of the thorax.
The nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. What is the main purpose of these nursing actions?
Prevent aspiration
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?
"Avoid coffee and alcoholic beverages."
A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate?
"It is a vent that prevents backflow of the secretions."
The nurse is teaching a client with a family history of oral cancer about the early stage of the disease. Which statement(s) should the nurse include in the teaching? Select all that apply.
"The early stage of oral cancer is characteristically asymptomatic." "A lesion, lump, or other abnormality may be present on the lips or mouth."
The nurse inserts a nasogastric tube into the right nares of a patient. When testing the tube aspirate for pH to confirm placement, what does the nurse anticipate the pH will be if placement is in the lungs?
6
Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery?
Vagus
A client is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate?
Wash the area around the tube with soap and water daily.
Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?
Weakness, diaphoresis, diarrhea 90 minutes after eating
A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate?
Hang a solution of dextrose 10% and water until the new solution is available.
The nurse is inserting a nasogastric tube and the patient begins coughing and is unable to speak. What does the nurse suspect has occurred?
The nurse has inadvertently inserted the tube into the trachea.
The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance?
260 Explanation: Intake includes all the components listed in the intake column, which amounts to 710 mL. The output, which is the urine of 450 mL, is subtracted from the total intake. This leaves 260 mL as a positive fluid balance.
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 with the patient in semi-Fowler's position to decrease the effect of gravity on transit time.
The nurse is inserting a nasogastric tube for a patient with pancreatitis. What intervention can the nurse provide to allow facilitation of the tube insertion?
Allow the patient to sip water as the tube is being inserted.
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
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?
Diagnosed with malabsorption syndrome
A nurse is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply.
Diarrhea Tachycardia Diaphoresis
A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client?
Dumping syndrome
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. Instruct the client to avoid alcohol or tobacco products. Instruct the client to eat slowly and chew the food thoroughly.
A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. What actions are a priority for the nurse to perform prior to administration? Select all that apply.
Ensure availability of an infusion pump Ensure completion of baseline monitoring of the complete blood count (CBC) and chemistry panel Place a 1.5-micron filter on the tubing
A nurse has obtained an order to remove a client's NG tube that was placed for feeding. What is the nurse's best initial action?
Explain the process clearly to the client.
The nurse assesses a patient who recently had a nasoenteric intubation. Symptoms of oliguria, lethargy, and tachycardia in the patient would indicate to the nurse what common complication?
Fluid volume deficit
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.
The client is receiving a 25% dextrose solution of parenteral nutrition. The infusion machine is beeping, and the nurse determines the intravenous (IV) bag is empty. The nurse finds there is no available bag to administer. What is the priority action by the nurse?
Infuse a solution containing 10% dextrose and water.
The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly?
Keep the vent lumen above the patient's waist to prevent gastric content reflux.
When assisting with the plan of care for a client receiving tube feedings, which of the following would the nurse include to reduce the client's risk for aspiration?
Keeping the client in a semi-Fowler's position at all times.
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)
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?
Levin tube
A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and would make a recommendation when noticing which circumstance?
No land line; cell phone available and taken by family member during working hours
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:
Proton pump inhibitors.
When a central venous catheter dressing becomes moist or loose, what should a nurse do first?
Remove the dressing, clean the site, and apply a new dressing.
An older adult patient who has been living at home alone is diagnosed with parotitis. What causative bacteria does the nurse suspect is the cause of the parotitis?
Staphylococcus aureus
A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge?
The client is free from esophagitis and achalasia.
The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length?
The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process
