Chapter 44: Digestive and Gastrointestinal Treatment Modalities

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 client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance?

260 mL

A client has been prescribed a protein intake of 0.6 g/kg of body weight. The client weighs 154 pounds. The nurse calculates the daily protein intake to be how many grams? Enter the correct number ONLY.

42 grams

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

A nurse is preparing to assist a health care provider with a peripherally inserted central catheter. The nurse demonstrates understanding of this procedure by preparing which insertion site?

Basilic vein

The primary source of microorganisms for catheter-related infections are the skin and which of the following?

Catheter hub

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 client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement (select all options that apply):

Compares exposed tube length with original measurement Visually assesses the color of the aspirate Checks the pH of the gastric contents

A nurse administered a full strength feeding with an increased osmolality through a jejunostomy tube to a client. Immediately following the feeding, the client expelled a large amount of liquid brown stool and exhibited a blood pressure of 86/58 and pulse rate of 112 beats/min. The nurse

Consults with the physician about decreasing the feeding to half-strength

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

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 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 client has been receiving intermittent tube feedings for several days at home. The nurse notes the findings as shown in the accompanying documentation. The nurse reports the following as an adverse reaction to the tube feeding:

Fasting blood glucose level

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.

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 following appears on the medical record of a male patient receiving parenteral nutrition: WBC: 6500/cu mm Potassium 4.3 mEq/L Magnesium 2.0 mg/dL Calcium 8.8 mg/dL Glucose 190 mg/dL Which finding would alert the nurse to a problem?

Glucose level

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.

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.

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.

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

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.

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?

Place the client in a semi-Fowler's position with the head of the bed at 45 degrees.

A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply.

Remove gas and fluids from the stomach Diagnose gastrointestinal motility disorders Flush ingested toxins from the stomach Administer nutritional substances

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.

A nurse suspects that a client is developing rebound hypoglycemia secondary to parenteral nutrition being discontinued too rapidly. Which assessment support the nurse's suspicion? Select all that apply.

Shakiness Tachycardia Weakness Confusion

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

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.

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 checks residual content before each intermittent tube feeding. When should the patient be reassessed?

When the residual is greater than 200 mL

A graduate nurse is cleaning a central venous access device (CVAD) and is being evaluated by the preceptor nurse. The preceptor nurse makes a recommendation for relearning the skill when she notes the graduate nurse does the following action:

Wipes catheter ports from distal end to insertion site

To ensure patency of central venous line ports, diluted heparin flushes are used

daily when not in use.

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.

The client is experiencing swallowing difficulties and is now scheduled to receive a gastric feeding. The client has the following oral medications prescribed: furosemide, digoxin, enteric coated aspirin, and vitamin E. The nurse would withhold which medication?

enteric coated aspirin

Rebound hypoglycemia is a complication of parenteral nutrition caused by

feedings stopped too abruptly.

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.

The nurse monitors a client with nasoenteric intubation. When should the nurse contact the physician?

urinary output 20 mL/hr

A nurse is interviewing a patient to determine suitability for home parenteral nutrition. Which patient statement would alert the nurse to a potential problem?

"I have a telephone, but it has been shut off because my bill is overdue."

A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is

Inserted into the lungs

The most significant complication related to continuous tube feedings is

the increased potential for aspiration.

A patient has a gastric sump tube inserted and attached to low intermittent suction. The physician has ordered the tube to be irrigated with 30 mL of normal saline every 6 hours. When reviewing the patient's intake and output record for the past 24 hours, the nurse would expect to note that the patient received how much fluid with the irrigation?

120 mL

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 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.

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 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 collaborates with the physician and dietician to determine the best type of tube feeding for a client at risk for diarrhea due to hypertonic feeding solutions. Which type of feedings should the nurse suggest?

continuous feedings