Invasives - Nutrition and Elimination

A nurse is calculating the total fluid intake for a client during an 8-hr period. The client has an IV bolus of 150 mL and consumed 4 oz of juice, 6 oz of hot tea, 100 mL of water, and 8 oz of clear broth. The nurse should record how many mL of intake on the client's record? ___________________________ mL

790 mL

A nurse is caring for a client who has a SBO from adhesions. Which of the following findings are consistent with this diagnosis? A - Emesis greater than 500 mL with fecal odor B - Reports os spasmodic abdominal pain C - High pitched Bowel sounds D - Abdomen flat with rebounding tenderness to palpation E - Lab findings indicating metabolic acidosis

A - Emesis greater than 500 mL with fecal odor B - Reports os spasmodic abdominal pain C - High pitched Bowel sounds

A nurse is discussing the use of a low profile gastrostomy device with the guardian of a child who is receiving an enteral feeding. Which of the following is an appropriate statement by the nurse? A - The device is usually comfortable for child B - CHecking residual is much easier with this device C - This access required less maintenance than a traditional nasal tube D - Mobility of the child is limited with this device.

A - The device is usually comfortable for child

A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should the nurse anticipate returning to the expected reference range within 72 hr after treatment begins? A - Aldolase B - Lipase C - Amylase D - Lactic dehydrogenase

C - Amylase Rational A - Elevated aldolase levels are caused by inflammation of the muscles, also known as myositis. The levels of aldolase are not affected by pancreatic disorders. B - Lipase levels in clients who have pancreatitis increase after a rise in serum amylase and stay elevated for up to 14 days longer than amylase. C- Pancreatitis is the most common diagnosis for marked elevations in serum amylase. Serum amylase begins to increase about 3 to 6 hr following the onset of acute pancreatitis. The amylase level peaks in 20 to 30 hr and returns to the expected reference range within 2 to 3 days. D - Lactic dehydrogenase (LDH) increases are typically seen in clients who have anemia, leukemia, or liver damage.

A nurse is teaching a client who recently had a myocardial infarction and has a new prescription for docusate sodium. The nurse should inform the client that docusate sodium has which of the following therapeutic effects? A - Reduces inflammation B - Reduces gastric acid C - Prevents diarrhea D - Prevents straining

D - Prevents straining Rational A- Docusate sodium does not have anti-inflammatory effects. Sulfasalazine, a 5-aminosalicylate, is a GI-system drug that reduces the inflammation of inflammatory bowel disease. B - Docusate sodium does not reduce gastric acid secretion. Omeprazole, a proton pump inhibitor, is a GI-system drug that reduces gastric acid secretion. C - Docusate sodium does not prevent diarrhea. Loperamide, an opioid agonist, is a GI-system drug that prevents or treats diarrhea. D -Docusate sodium, a stool softener, prevents straining during defecation and prevents the elevation in blood pressure that can result from straining. It also helps relieve constipation and reduces the painful elimination of hard stools.

To prevent aspiration during the administration of an enteral tube feeding, a nurse should A - flush the feeding tube with 30 mL of water. B - add blue food coloring to the enteral formula. C - ensure the formula is at room temperature. D - place the patient in Fowler's position.

D - place the patient in Fowler's position. Rational A- Flushing the tube with water before and after administering a tube feeding helps ensure that the tube is patent and clear of any formula that could obstruct the tube. This is not done to prevent aspiration prior to feeding. B - Although this practice was once used to help detect formula aspirated into the lungs by staining airway secretions, it has been associated with patients' deaths and is therefore no longer considered safe practice. C - Although administering tube feeding formula at room temperature is preferable, it is done primarily to prevent stomach cramps. D - The Fowler's position is recommended during tube feeding to reduce the risk of regurgitation, which can lead to aspiration. If Fowler's is uncomfortable for the patient, an acceptable alternative is elevating the head of the bed at least 30°.

A nurse is collecting data from a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? A - High-calorie diet B - Prior gastrointestinal illnesses C - Tobacco use D -Alcohol use

D -Alcohol use Rational A - A high-calorie diet can contribute to heart disease and obesity. However, it does not cause or contribute to chronic pancreatitis. B - A prior gastrointestinal illness does not cause or contribute to chronic pancreatitis. C - Tobacco use can contribute to heart disease and increases the risk of cancer development. However, it does not cause chronic pancreatitis. D - Alcohol consumption is one of the major causes of chronic pancreatitis in the U.S. Long-term alcohol use disorder produces hypersecretion of protein in pancreatic secretions. The result is protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage to these cells is more likely to occur and to be more severe in clients whose diets are poor in protein content and either very high or very low in fat.

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene? A. The nurse initiates the feeding after aspirating 50 mL of gastric residual B. The nurse irrigates the NG tube with tap water after feeding C. The nurse administers the feeding through a syringe barrel by gravity D. The nurse allows the client to rest in a supine position during feeding

D. The nurse allows the client to rest in a supine position during feeding Rational A - The nurse should withhold the feeding if the residual exceeds 100 mL or the amount the facility's policy specifies. It is generally safe to proceed after finding 50 mL of gastric residual. B - The nurse should flush the tubing with 50 to 100 mL of tap water after feedings and medication administration to prevent clogging. The stomach is not sterile, so tap water is acceptable. C - After removing the plunger, the nurse should pour the formula into a 60-mL syringe and allow it to flow by gravity. The nurse can adjust the flow by raising or lowering the syringe. D - The nurse should position the head of the bed at a minimum of 30⁰ of elevation to prevent aspiration from reflux during feedings.

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? A. To confirm the placement of the NG tube B. To remove gastric acid that might cause dyspepsia C. To determine the client's electrolyte balance D. To identify delayed gastric emptying

D. To identify delayed gastric emptying Rational A - The nurse should test the pH of the gastric residual to help confirm NG tube placement. B - Unless the residual exceeds 100 mL or the amount specified by facility's policy, the nurse should return it to the stomach. C - Measuring gastric residual does not yield any data about the client's fluid and electrolyte balance. Laboratory testing of the client's blood for electrolytes would provide this information. D - The nurse measures the amount of unabsorbed formula from the previous enteral feeding to identify delayed gastric emptying. If it is delayed, the nurse should avoid overfeeding the client and causing gastric distention.

What type of diet should be encouraged for patients with pancreatitis?

Low fat and frequent meals Lack of enzymes to break fat down = fatty stools

A nurse is planning care for a client who has anorexia and has manifestations of malnutrition. When reviewing the client's laboratory values, which of the following test results should the nurse expect to be low? A - ​D-dimer ​B - Troponin ​C - Creatinine ​D - Albumin

​D - Albumin Rational A - D-dimer determines intravascular clotting, not malnutrition. B - Troponin levels help determine myocardial injury and inflammation, not malnutrition. C - Creatinine reflects renal function, not nutritional status. D - A low albumin level indicates malnutrition, as well as renal disease, infection, severe burns, and liver dysfunction.

A nurse is reinforcing discharge teaching with a client who is receiving intermittent enteral feedings through a gastrostomy tube. Which of the following client statements requires further teaching by the nurse? A - "I can crush and mix my medication with my formula." B - "I will return all aspirated gastric residual volume before each bolus feeding." C - "I need to flush the tube with 15 to 30 mL of water before and after each bolus feeding." D - "I should make sure the formula is at room temperature before instilling down my tube."

A - "I can crush and mix my medication with my formula." Rational A - The client should crush the medication or obtain a liquid form of the medication and administer after or before intermittent feedings. Administering medication mixed with an enteral feeding can lead to clogging of the tube. B - The client should return all aspirated gastric residual volume to maintain electrolytes and digestive enzymes and to receive proper amount of nutrients. C - The client should flush the gastrostomy tube with 15 to 30 mL of water before and after each feeding to ensure patency and prevent clogging of the tube with formula. D - The client should have the formula at room temperature to decrease abdominal cramping.

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via NG tube. Which actions should the nurse complete prior to administering the tube feeding? A - Auscultate bowel sounds B - Assist the client to an upright position C - Test the pH of the gastric aspirate D - Warm the formula to body temperature E - Discard any gastric residual contents.

A - Auscultate bowel sounds B - Assist the client to an upright position C - Test the pH of the gastric aspirate

A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? A - Children and young adults B - Older adults C - Women who are pregnant D -Middle-aged men

A - Children and young adults Rational A- The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The hepatitis A virus can be contracted from the feces, bile, and blood of infected clients. The usual mode of transmission is the fecal-oral route. Children and young adults are the two groups most often affected by the hepatitis A virus. Typically, a child or young adult acquires the infection at school, through poor hygiene, hand-to-mouth contact, or another form of close contact. B - Older adults are not often affected by or at risk for developing hepatitis A. C - Women who are pregnant are not often affected by or at risk for developing hepatitis A. D - Middle-aged men are not often affected by or at risk for developing hepatitis A.

A nurse is contributing to the plan of care for a client who has a SBO and has an NG tube in place. Which of the following interventions should the nurse include? A - Document NG drainage with the client's output helps determine if fluid replacement is indicated B - Irritate the NG tube every 8 hours C - Monitor Bowel Sounds D - Ensure the client is in semi-fowlers position E - Monitor NG tube placement.

A - Document NG drainage with the client's output helps determine if fluid replacement is indicated C - Monitor Bowel Sounds D - Ensure the client is in semi-fowlers position E - Monitor NG tube placement. Rational B - Every 4 hours

An older adult patient in a long-term care facility is receiving intermittent enteral feedings in his room. His affect is flat, and the nurse suspects that he is feeling isolated. Which of the following interventions is appropriate for this patient? A - Encourage him to go to the dining room at meal times to talk with other patients. B - Suggest that he watch television while his feedings are being administered. C - Remind him that he can have visitors after his feeding administration times. D - Ask the facility chaplain to speak with the patient.

A - Encourage him to go to the dining room at meal times to talk with other patients. Rational A - By encouraging the resident to maintain a normal schedule and social interactions, the nurse is helping to rebuild his social network and reverse patterns of isolation. B - Although television can provide a useful distraction for some patients and might actually help improve this patient's mood, this diversion is not interactive; therefore, it is unlikely to reduce any feelings of isolation he might have. C - Although visitation policies vary with the facility, generally visitors are permitted during meal times in long-term care facilities. This intervention will not improve the situation if the patient does not have a family and social network outside the facility. D -It is inappropriate to contact the chaplain without first consulting with the patient.

A nurse is assisting with the care of a client who has a history of cirrhosis and is admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? A - Gamma-glutamyl transferase (GGT) B - Alkaline phosphatase (ALP) C - Serum bilirubin D - Alanine aminotransferase (ALT)

A - Gamma-glutamyl transferase (GGT) Rational A - The GGT laboratory test is specific to the hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. Therefore, it is useful for monitoring for drug toxicity and excessive alcohol use. B - ALP is elevated in biliary obstruction and most forms of liver dysfunction. It does not differentiate between alcohol and other causative factors for liver disease. C - The serum bilirubin test is used to detect the function of the liver and its ability to excrete bilirubin. Elevated levels can determine liver disease or biliary tract disease. D - The largest concentration of the enzyme ALT is found in liver tissue. However, it is also present in kidney, heart, and skeletal muscle tissues. Because it is elevated in various types of tissue damage, it is not helpful in identifying excessive alcohol use.

A nurse is reinforcing nutrition reaching with a client who has pancreatitis. Which of the following statements indicates an understanding of the instructions? A - I plan to eat small frequent meals B - I will eat easy to digest foods with limited spice C - I will use skin milk for cooking D - I plan to drink regular cola E - I will limit alcohol intake to 2 drinks per day

A - I plan to eat small frequent meals B - I will eat easy to digest foods with limited spice C - I will use skin milk for cooking

A nurse is performing a nasogastric intubation. Which of the following actions should the nurse take immediately after inserting the tube to the predetermined length? A - Inspect the oropharynx with a penlight and a tongue blade. B - Obtain an x-ray examination of the chest and abdomen. C - Tape the tube securely in place with a tube holder device. D - Aspirate gastric contents.

A - Inspect the oropharynx with a penlight and a tongue blade. Rational A - After insertion, the nurse should immediately inspect the oropharynx to check for kinks and to ensure that the tube is not coiled. B -Obtaining an x-ray examination of the chest and abdomen should be done after nasogastric intubation, but it is not the immediate action the nurse should take. C - The tube should be secured in place after nasogastric intubation, but this is not the immediate action the nurse should take. D - Aspirating for gastric contents should be done after nasogastric intubation, but it is not the immediate action the nurse should take.

A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following laboratory findings should the nurse monitor prior to the procedure? A - Prothrombin time B - Serum lipase C - Bilirubin D - Calcium

A - Prothrombin time Rational A- A major complication following a liver biopsy is hemorrhage. Many clients who have liver disease have clotting defects and are at risk for bleeding. Along with the prothrombin time (PT), the activated partial thromboplastin time (aPTT) and the platelet count should be monitored. Liver dysfunction causes the production of blood clotting factors to be reduced, which leads to an increased incidence of bruising, nosebleeds, bleeding from wounds, and gastrointestinal bleeding. This is due to a deficient absorption of vitamin K from the gastrointestinal tract caused by the inability of liver cells to use vitamin K to make prothrombin. B - Serum lipase is monitored to detect pancreatic disease and does not need to be monitored prior to this procedure. C - Bilirubin is monitored to detect biliary obstruction and does not need to be monitored prior to this procedure. D - Calcium is monitored to detect kidney failure or pancreatitis and does not need to be monitored prior to this procedure.

A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following should the nurse perform before beginning the procedure? A - Review a signal the client can use if feeling any distress B - Lay a towel across the client's chest C - Administer oral pain medication D - Obtain a Dobhoff tube for insertion E - Have petroleum based lubricant available

A - Review a signal the client can use if feeling any distress B - Lay a towel across the client's chest

A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? A - Right shoulder pain B - Urine output 20 mL/hr C - Temperature 38.4° C (101.1° F) D - Oxygen saturation 92%

A - Right shoulder pain Rational A- The client can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1 to 2 days. Mild analgesics and a recumbent position can help relieve client pain. B - Urine output following surgery should be at least 30 mL/hr. Less than this amount can indicate hypovolemia or renal complications and should be reported to the provider immediately. C - A temperature greater than 38.4° C (101.1° F) can indicate infection and should be reported to the provider immediately. D - An oxygen saturation of less than 95% can indicate an impaired gas exchange following surgery and should be reported to the provider immediately.

A nurse is delivering an enteral feeding to a client who has an NG in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe the client asks why the water is necessary. Which of the following responses should the nurse make? A - Water helps ceal the tube so it doesn't get clogged B - Flushing helps make sure the tube stays in place C - This will help you get enough fluids D - Adding water makes the formula less concentrated so you can tolerate it better .

A - Water helps ceal the tube so it doesn't get clogged

A nurse is caring for a patient who has a newly inserted nasogastric tube. Which of the following methods is appropriate for verifying the initial placement? A - X-ray examination of the chest and abdomen B - Auscultation of injected air C - pH measurement of gastric aspirate D - Color of gastric contents

A - X-ray examination of the chest and abdomen Rational A - X-ray examination is the gold standard for confirming the initial placement of a nasogastric tube. B - Injecting air into the tube and listening over the abdomen is not acceptable practice and has been found unreliable in verifying tube placement. C - The pH measurement of gastric aspirate is 4 or less. This can be used to monitor placement after the initial placement has been verified. D- Gastric contents are usually cloudy and green. This can assist in monitoring placement, but it should not be used to verify the initial placement

To prevent a common complication of continuous enteral tube feedings, a nurse should A - limit the time the formula hangs to 4 hr. B - chill the formula prior to administration. C - deliver the formula at a brisk rate. D - allow the feeding bag to empty before refilling it.

A - limit the time the formula hangs to 4 hr. Rational A- Formula that hangs longer than 4 to 8 hr is at risk for bacterial contamination, typically manifested by the patient as diarrhea. B - It is recommended that enteral formula be warmed to room temperature prior to administration. Cold formula can cause abdominal cramping. C - Administering enteral formula too fast (generally, more than 200 to 300 mL over 10 to 20 min) can cause abdominal cramping, nausea, and vomiting. A lower rate of delivery improves tolerance. D - This can result in an excessive infusion of air, which could cause vomiting.

A nurse is reviewing medications for a client who has just been diagnosed with a small bowel obstruction. The nurse should withhold senna prescribed orally bases on understanding of which of the following? A -Laxatives are contraindicated in clients who have a small bowel obstruction. B - Bulk-forming laxatives such as psyllium should be substituted for this client. C - The prescribed medication should be administered via NG route rather than the oral route for this client. D - An osmotic laxative, such as magnesium citrate, should be substituted in this client.

A -Laxatives are contraindicated in clients who have a small bowel obstruction. Rational A - Senna is a stimulant laxative and, like other laxatives, is contraindicated in clients who have fecal impaction, bowel obstruction, and acute abdominal surgery to prevent perforation. Because the bowel does not allow for any passage of stool with a complete small bowel obstruction, laxatives will cause increased abdominal cramping and discomfort and might cause perforation of the bowel. B - Bulk-forming laxatives such as psyllium are contraindicated in clients who have small bowel obstructions because they soften the fecal mass and increase the bulk of the stool. C - Administering laxatives by both oral route and through use of a nasogastric tube is contraindicated for a client who has a bowel obstruction. D - Osmotic laxatives are contraindicated for clients who have a small bowel obstruction because these laxatives cause water to be retained in the bowel and promote swelling and increased peristalsis, which could cause perforation.

A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove from the client's meal tray? A- Wheat toast B - Tapioca pudding C - Hard-boiled egg D - Mashed potatoes

A- Wheat toast Rational A - Celiac disease is an autoimmune disorder characterized by a permanent intolerance to wheat, barley, and rye. Wheat toast contains gluten and should be removed from the client's tray. B - Tapioca pudding is rich in dairy and does not contain gluten. Therefore, it is an acceptable food to include in the client's diet. C - A hard-boiled egg is a good source of protein and does not contain gluten. Therefore, it is an acceptable food to include in the client's diet. D - Mashed potatoes do not contain gluten and are a good source of protein and potassium. Therefore, mashed potatoes are an acceptable food to include in the client's diet.

A nurse is administering several medications via a client's gastronomy tube. At which of the following times should the nurse instill 15 to 30 mL of warm water? Select all A. After each medication B. Before aspirating gastric contents C. When the flow of the medication by gravity slows D. Prior to administering each medication E. After giving multiple medications

A. After each medication D. Prior to administering each medication E. After giving multiple medications Rational A - After each medication is correct. Instilling water after each medication promotes flow and prevents clogging and chemical mixing of the medications within the tube. After instilling medications, the nurse should use sterile water to flush the tube because chemicals in tap water could interact with some medications. B - Before aspirating gastric contents is incorrect. Adding water prior to aspirating stomach contents would yield a falsely high volume and alter the pH. C - When the flow of the medication by gravity slows is incorrect.When the flow of medication into the stomach slows, the nurse should raise the syringe to allow gravity to draw the fluid into the stomach. D - Prior to administering each medication is correct. Instilling water through the tube before administering medications clears the tube of remaining stomach contents after aspiration and helps keep the tube patent. Before instilling medications, the nurse should use sterile water to flush the tube because chemicals in tap water could interact with some medications. E - After giving multiple medications is correct. After administering several medications via the gastrostomy tube, the nurse should instill another 15 to 30 mL of warm water to clear the tube.

A nurse is assisting in the plan of care for a client who has surgery for a bowel obstruction. The client nasogastric tube in place. Which of the following actions should the nurse include in the client's plan of care? (select all) A. Perform leg exercises every 2 hr B. Encourage hourly use of an incentive spirometer while awake C. Document the color, consistency, and amount of nasogastric drainage D. Irrigate the nasogastrictic every 4 to 8 hrs E. Maintain bed rest for 48 hr following surgery

A. Perform leg exercises every 2 hr B. Encourage hourly use of an incentive spirometer while awake C. Document the color, consistency, and amount of nasogastric drainage Rational A- Perform leg exercises every 2 hr is correct. Postoperative clients should frequently perform leg exercises, independently or with assistance, to prevent skin breakdown. B - Encourage hourly use of an incentive spirometer while awake is correct. Postoperative clients should be encouraged to use the incentive spirometer ten times each hour while awake to prevent atelectasis. C - Document the color, consistency, and amount of nasogastric drainage is correct. Documenting the color, consistency, and amount of nasogastric drainage is appropriate to include in the client's plan of care. D - Irrigate the nasogastric tube every 4 to 8 hr is incorrect. Following abdominal surgery, the NG tube should not be moved or irrigated unless prescribed by the provider. E - Maintain bed rest for 48 hr following surgery is incorrect. Maintaining bed rest following surgery should not be included in the plan of care. Early ambulation prevents distention and improves intestinal mobility.

A nurse is caring for a client who is receiving total parenteral nutrition. The nurse should monitor the client for which of the following conditions as a complication of TPN? A. Polyuria B. Aspiration C. Abdominal distension D. Stomatitis

A. Polyuria Rational A - TPN contains a high concentration of dextrose and minerals, placing the client at risk for hyperglycemia or fluid and electrolyte imbalance. The nurse should monitor blood glucose for clients receiving TPN. B - ​The nurse should identify aspiration as a potential complication of enteral nutrition therapy. This can occur if the tube is not placed correctly (e.g., in the lungs instead of the stomach), if feedings are administered too rapidly or in too large a volume, or the client's head is in a low position. C - ​The nurse should identify abdominal cramping as a potential complication of enteral nutrition therapy. Intolerance of the feeding can cause abdominal cramping or distention. For clients receiving enteral nutrition, the nurse should check residuals and measure the client's abdominal girth at the umbilicus. D - ​The nurse should identify stomatitis as a potential complication of chemotherapy. Stomatitis is an inflammation of the lining of the mouth that can include the inside of the cheeks, gums, and tongue.

A nurse is assisting with the development of an education program about nutritional risk among adolescents to a group of parents of adolescents. Which of the following information should the nurse include in the teaching? Select all A. Skipping more than three meals per week B. Eating fast food once weekly C. Hearty appetite D. Eating without family supervision frequently E. Frequently skipping breakfast

A. Skipping more than three meals per week D. Eating without family supervision frequently E. Frequently skipping breakfast Rational A - Skipping more than three meals per week is correct. Skipping more than three meals per week is an indicator of nutritional risk among adolescents, and should be included in the program. B - Eating fast food once weekly is incorrect. Eating fast food more than three times per week, not once weekly, is an indicator of nutritional risk among adolescents. C - Hearty appetite is incorrect. A poor appetite, not a hearty appetite, is an indicator of nutritional risk among adolescents. D - Eating without family supervision frequently is correct. Eating without family supervision frequently is an indicator of nutritional risk among adolescents, and should be included in the program. E - Frequently skipping breakfast is correct. Frequently skipping breakfast is an indicator of nutritional risk among adolescents, and should be included in the program.

A nurse is reinforcing teaching with a group of community residents about hepatitis B. Which of the following statements should the nurse include in the teaching? A - "A hepatitis B immunization is recommended for those who travel, especially military personnel." B - "A hepatitis B immunization is given to infants and children." C -"Hepatitis B is acquired by eating foods that are contaminated during handling." D - "Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation."

B - "A hepatitis B immunization is given to infants and children." Rational A - The hepatitis A vaccine is recommended for those who travel, especially military personnel. It is also recommended for other at-risk groups. B - Hepatitis B immune globulin is given as part of the standard childhood immunizations. It can be administered as early as birth, especially in infants born to hepatitis B surface antigen (HBsAg) negative mothers. These infants should receive the second dose between 1 and 4 months of age. C - Hepatitis A is acquired by eating fruits, vegetables, shellfish, or other foods that are contaminated during handling. Hepatitis B is acquired by exposure to blood or body fluids from an infected person. D - Good personal hygiene habits and proper sanitation can help prevent the spread of hepatitis A.

A nurse is reinforcing teaching with a client who has Barrett's esophagus and is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? A - "This procedure is performed to measure the presence of acid in your esophagus." B - "This procedure can determine how well the lower part of your esophagus works." C - "This procedure is performed while you are under general anesthesia." D - "This procedure can determine if you have colon cancer."

B - "This procedure can determine how well the lower part of your esophagus works." Rational A - A pH probe study, which involves the insertion of a specially designed probe into the distal esophagus, is performed to monitor for the presence of acid in the normally alkaline esophagus. B - An EGD is useful in determining the function of the esophageal lining and the extent of inflammation, potential scarring, and strictures. C - An EGD is performed while the client receives moderate sedation. D - A colonoscopy is performed to detect colon cancer.

A nurse is collecting data from a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect? A - Jaundice B - Anorexia C -Dark urine D - Pale feces

B - Anorexia Rational A - Jaundice is a late manifestation of hepatitis A. B - Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product. C - Dark urine is a late manifestation of hepatitis A. D - Pale feces is a late manifestation of hepatitis A.

When checking for nasogastric tube placement, the nurse should conduct which of the following procedures? A - Instill 20 mL of air into the tube and listen for a whooshing sound. B - Aspirate stomach contents and check the pH. C - Aspirate stomach contents and check their color. D - Auscultate lung sounds.

B - Aspirate stomach contents and check the pH. Rational A - This is no longer considered safe practice for checking tube placement. B - Checking the pH of stomach contents is the recommended method for checking tube placement. C - Though a component of assessing the stomach aspirate, checking the color is not the recommended method for determining tube placement. D - If an aspiration is suspected, auscultating the lungs would be an important assessment component, but this is not part of a routine check of nasogastric tube placement.

Which of the following formulas is appropriate to administer to a patient who has a dysfunctional gastrointestinal tract? A - Modular B - Elemental C - Polymeric D - Specialty

B - Elemental Rational A - Modular formulas are single-nutrient formulas and require a functioning gastrointestinal tract that can absorb whole nutrients. B - Elemental formulas contain predigested nutrients that are easy for a partially functional gastrointestinal tract to absorb. C - Polymeric formulas are whole-nutrient formulas and require a functioning gastrointestinal tract that can absorb whole nutrients. D - Specialty formulas meet specific needs of patients who have a particular disorder (HIV, liver failure), and they are not necessarily formulated for a patient with a nonfunctioning gastrointestinal tract.

A nurse is reviewing the medical record of a client who has a new prescription for ranitidine. The nurse should recognize that which of the following drugs interacts with ranitidine? A - Phenobarbital sodium B - Ketoconazole C - Lisinopril D - Hydrochlorothiazide

B - Ketoconazole Rational A- Phenobarbital sodium does not interact with ranitidine. However, it interacts with several types of drugs, including anticoagulants, oral contraceptives, and anticonvulsants. B - Ranitidine reduces the absorption of ketoconazole. C - Lisinopril does not interact with ranitidine. However, lisinopril interacts with lithium carbonate and can cause lithium toxicity. D -Hydrochlorothiazide does not interact with ranitidine. However, it acts by promoting potassium loss and increases the risk of digoxin toxicity.

A patient with a gastric ileus postoperatively requires nutritional support for approximately 2 weeks. Which of the following types of feeding tubes is appropriate for this patient? A - Nasogastric tube B - Nasointestinal tube C -Percutaneous endoscopic gastrostomy tube D - Percutaneous endoscopic jejunostomy tube

B - Nasointestinal tube Rational A - A lack of motility in the stomach (gastric ileus) would prevent the digestion of enteral formula placed in the stomach. B - A nasointestinal tube allows postpyloric feeding by depositing enteral formula directly into the intestines. This is an appropriate choice for a patient who lacks stomach motility (gastric ileus) and requires short-term (less than 4 weeks) enteral feeding. C - A lack of motility in the stomach (gastric ileus) would prevent the digestion of enteral formula placed in the stomach. D - Placing enteral formula into the jejunum rather than the stomach is appropriate for a patient who lacks stomach motility (gastric ileus). However, a percutaneous tube is indicated for patients who require enteral feedings for more than 4 weeks.

A nurse is preparing to administer pancrelipase to a client with pancreatitis. Which of the following action should the nurse take? A - Instruct the client to chew the med prior to swallowing B - Offer a glass of water following the med admin C - Administer the med 30 minutes before meals D - Spring the contents on peanut butter

B - Offer a glass of water following the med admin With meals and snack

A nurse is providing teaching to a patient who is receiving intermittent nasogastric feedings. Which of the following should the nurse instruct the patient to report immediately? A - A feeling of fullness B - Persistent coughing C - Discomfort in the naris D - Postfeeding belching

B - Persistent coughing Rational A- This is a normal finding after intermittent feedings. It is not likely to be a cause for concern unless the feeling persists or triggers vomiting or if gastric residuals exceed 100 mL. B - This could indicate that the distal end of the nasogastric tube has moved into the respiratory tract. Immediate assessment is needed, because the patient might be at risk for aspiration. C - Friction from the presence of the tube can be uncomfortable and indicates a need for ongoing assessment; however, this does not need to be reported immediately. D - This may be a normal finding depending on the composition of the formula and the patient's usual response to the nutrients.

A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? A - Flush the tube with water. B - Place the client in semi-Fowler's position. C - Cleanse the skin around the tube site. D- Aspirate the tube prior to each feeding.

B - Place the client in semi-Fowler's position. Rational A - A client receiving PEG tube feedings should have the tube thoroughly flushed. However, there is another action the nurse should take first. B - The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second priority in the ABC priority-setting framework because adequate ventilatory effort is essential for oxygen exchange to occur. Circulation is the third priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. A client who is receiving PEG tube feedings should be positioned with the head of the bed elevated at least 30° during and after feedings to decrease the risk of aspiration. Therefore, this is the priority action by the nurse. C - A client who has a PEG tube requires frequent observation and good skin hygiene at the insertion site to prevent breakdown and irritation. However, there is another action the nurse should take first. D - Prior to each feeding, the PEG tube should be aspirated for residual gastric contents from the previous feeding. However, there is another action the nurse should take first.

A patient recovering for gastric surgery remain NPO and has a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membranes? A - Allow the patient to suck on ice chips. B - Provide frequent mouth care. C - Apply petroleum jelly to the patient's naris. D -Offer throat lozenges for the patient to use.

B - Provide frequent mouth care. Rational A - Ice chips are contraindicated for a patient who is NPO status, especially for one who just underwent gastric surgery. B - Frequent mouth care (brushing teeth, oral swab) is a nursing intervention that prevents mucous membranes from becoming dry and irritated. C -Petroleum jelly should not be used due to the risk of aspiration. Non-petroleum based ointment should be used. D - Throat lozenges are contraindicated for a patient who is NPO status, especially for one who just underwent gastric surgery.

A nurse is instructing a client on how to administer cyclic enteral feedings at home. Which of the following should the nurse include? A - Give a feeding every 6 hours B - Set the feeding up before you go to bed C - Weigh yourself daily D - Flush the tube with a carbonated beverage to dislodge clogs E - Ensure your head is elevated 15 degrees during administration

B - Set the feeding up before you go to bed C - Weigh yourself daily

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following interventions is the highest priority when the nurse suspects aspiration of the feeding? A - Auscultate breath sounds B - Stop the feeding C - Obtain a CXR D - Initiate oxygen therapy

B - Stop the feeding

A nurse is collecting data from a client who is receiving chemotherapy and is showing manifestations of malnutrition. Which of the following indicates a Vitamin C deficiency? A - Dry, red conjunctiva B - Swollen, bleeding gums C - Inflammation of the tongue D - Pale, brittle nails

B - Swollen, bleeding gums Rational A - The client who is malnourished can have dry, red conjunctiva; however, it is a result of vitamin A deficiency. B - The client who is malnourished can have swollen, bleeding gums from a vitamin C deficiency. C - The client who is malnourished can have inflammation of the tongue; however, it is a result a deficiency of B vitamins. D - The client who is malnourished can have pale, brittle nails; however, it is a result of iron deficiency.

A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that the purpose of this procedure is which of the following? A - To visualize colon polyps B - To detect an ulceration in the stomach C - To identify an obstruction in the biliary duct D - To determine the presence of free air in the abdomen

B - To detect an ulceration in the stomach Rational A - A sigmoidoscopy or barium enema is used to visualize the lower gastrointestinal tract, where polyps are found. B - An EGD is used to visualize the esophagus, stomach, and duodenum with a lighted tube to detect tumors, ulcerations, or obstructions. C - Identifying an obstruction in the biliary duct is performed by using endoscopic retrograde cholangiopancreatography (ERCP). D - The measurement of free air, which is a gas, is obtained using fluoroscopy or an x-ray, not an EGD.

A nurse is reviewing the chart of a client who has a SBO. Which of the following should the nurse report to the provider? A - Emesis prior to the insertion of the NG tube B - Urine specific gravity of 1.040 C - Hct 60% D - WBC 10,000 E - High pitched bowel sounds.

B - Urine specific gravity of 1.040 C - Hct 60% E - High pitched bowel sounds.

A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which action is the nurse's highest assessment priority before performing this procedure? A - Check how long the feeding container has been open B - Verify the placement of the NG tube C - Confirm that the client does not have diarrhea D - Make sure the client is alert and oriented.

B - Verify the placement of the NG tube

A nurse is reinforcing discharge teaching for a client who has chronic pancreatitis. Which of the following statements by the nurse is appropriate? A. "You should decrease your caloric intake when abdominal pain is present." B. "You should increase your daily intake of protein." C. "You should increase fat intake when experiencing loose stools." D. "You should limit alcohol intake to 2 to 3 drinks per week."

B. "You should increase your daily intake of protein." Rational A - The client who has chronic pancreatitis is at risk for malnutrition and should increase caloric intake in order to maintain weight. B - The client who has chronic pancreatitis should consume a diet that is high in protein to maintain muscle strength and for tissue repair. C - The client who has chronic pancreatitis should consume a low-fat diet to prevent stimulation of the pancreas and steatorrhea. D - The client who has chronic pancreatitis should avoid alcohol intake to prevent stimulation of the pancreas.

A nurse is caring for a client who has a cognitive impairment and repeatedly pulls on his NG tube. Which of the following interventions should the nurse consider before requesting a prescription for restraints? Select all A. Explain that restraints will be the next step B. Assist with toileting at frequent intervals C. Use an electronic position sensing device D. Provide diversionary activities E. Involve the family in the clients care

B. Assist with toileting at frequent intervals C. Use an electronic position sensing device D. Provide diversionary activities E. Involve the family in the clients care Rational A - Explain that restraints will be the next step is incorrect. Others could perceive this action as a threat. B - Assist with toileting at frequent intervals is correct. Clients who have a cognitive impairment can become restless and agitated and pull at the NG tube when they have elimination needs. C - Use an electronic position sensing device is correct. These devices can alert the nurse to times when the client is particularly restless or agitated. D - Provide diversionary activities is correct. Distracting the client from the NG tube might keep him from dislodging it. E - Involve the family in the client's care is correct. The client's family might know of effective alternatives to restraint for this client.

A nurse is caring for a client who is postoperative and has an NG tube that has drained 2,500 mL in the past 6 hr. The nurse should monitor the client for which of the following electrolyte imbalances? A. Elevated sodium level B. Decreased potassium level C. Elevated magnesium level D. Decreased calcium level

B. Decreased potassium level Rational A - Loss of gastric fluid does not increase sodium levels. Hypernatremia results from endocrine imbalances and excessive salt intake. B - Loss of gastric fluid is a common cause of potassium depletion. C - Loss of gastric fluid does not increase magnesium levels. Hypermagnesemia is a result of renal failure or excessive magnesium intake. D - Loss of gastric fluid does not reduce calcium levels. Hypocalcemia is a result of renal failure, cellular damage, or other metabolic disorders.

A nurse is reinforcing teaching about nutrition with a parent of a toddler. Which of the following statement should the nurse include in the teaching? A. Toddlers have increased appetites B. Toddlers have a decreased nutritional need C. Offer foods that are mixed together D. Fill the plate with multiple food choices

B. Toddlers have a decreased nutritional need Rational A - Toddlers experience a decrease in appetite. B - Toddlers have a decrease in nutritional needs and tend to eat less because their growth rate has slowed. C - Toddlers prefer to have food choices separated and visually appealing. D - Toddlers like small amounts of food as options at mealtime. A large amount of food is likely to overwhelm the toddler.

A nurse should recognize that nasogastric intubation is indicated to relieve gastric distention for which of the following patients? A - A 6-year-old child who drank a toxic substance B - A 60-year-old patient admitted with gastrointestinal hemorrhage C - A 40-year-old patient with a postoperative bowel obstruction D - A 20-year-old patient with malabsorption syndrome

C - A 40-year-old patient with a postoperative bowel obstruction Rational A - In this case, a nasogastric tube would be placed for lavage, which is irrigation of the stomach in cases of poisoning. B - In this case, a nasogastric tube would be placed for compression, which is an internal application of pressure by inflating a balloon. This can assist in preventing gastrointestinal hemorrhage. C - A nasogastric tube should be placed for decompression for the removal of secretions. This will assist in relieving abdominal distention. D - In this case, a nasogastric tube would be placed for feeding. This will allow for enteral feedings.

A nurse is reinforcing teaching with a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend? A - Foods high in vitamin C B - Foods low in fat C - Foods high in fiber D - Foods low in calories

C - Foods high in fiber Rational A - Vitamin C functions as an antioxidant as well as a coenzyme. It can be associated with prevention of cancer of the stomach, esophagus, and colon. However, it does not improve or prevent acute diverticulitis attacks. B - Low-fat foods do not improve or prevent diverticulitis attacks. C - The result of long-term, low-fiber eating habits along with increased intracolonic pressure lead to straining during bowel movements, causing the development of diverticula. High-fiber foods help strengthen and maintain active motility of the gastrointestinal tract. D - Low-calorie foods do not improve or prevent diverticulitis attacks.

A nurse is collecting data from a client who has pancreatitis. Which of the following findings should the nurse identify as manifestation of pancreatitis? A - Generalized cyanosis B - Hyperactive BS C - Gray-blue discoloration around the umbilicus D - Wheezing in the lower lung field

C - Gray-blue discoloration around the umbilicus

A nurse is assisting with the admission of a client who has fulminant hepatic failure. Which of the following procedures should the nurse expect for this client? A - Endoscopic sclerotherapy B - Liver lobectomy C - Liver transplant D - Transjugular intrahepatic portal-systemic shunt placement

C - Liver transplant Rational A - Endoscopic sclerotherapy is the injection of a sclerotherapy agent during endoscopy to target esophageal varices that are actively bleeding. This is not a procedure the nurse should expect for this client. B - A liver lobectomy is used for a client who has localized cancer of a lobe of the liver. This is not a procedure the nurse should expect for this client. C - Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients. D - A transjugular intrahepatic portal-systemic shunt is placed to treat esophageal varices through placement of a stent into the portal vein. The stent serves as a shunt between the portal circulation and the hepatic vein, thereby reducing portal hypertension. It is not used for fulminant hepatic failure.

A nurse is checking a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occurred? A - Elevated blood pressure B - Bowel sounds increased in frequency and pitch C - Rigid abdomen D - Emesis of undigested food

C - Rigid abdomen Rational A - A client who has experienced a bowel perforation will not display an elevated blood pressure. However, hypotension or shock can be present. B - Intestinal peristalsis increases in frequency and intensity as the bowel attempts to move intestinal contents past the obstructed area. Bowel sounds are silent with a bowel perforation. C - Abdominal tenderness and rigidity occur with a bowel perforation. As fluid escapes into the peritoneal cavity, there is a reduction in circulating blood volume and a lowered blood pressure, or hypotension, results. D - Vomiting is frequent and copious with a small bowel obstruction. This does not indicate a bowel perforation.

During report, a nurse is informed that a patient has a nasogastric tube connected to continuous suction. The nurse should recognize that this patient must have which of the following types of tube? A - Levin B - Sengstaken-Blakemore C - Salem sump D - Ewald

C - Salem sump Rational A - A Levin tube is a single-lumen tube that requires intermittent suction to drain stomach secretions. B - A Sengstaken-Blakemore tube is one in which a balloon is inflated to apply internal pressure to prevent esophageal or gastrointestinal bleeding. C - A Salem sump is the only type of tube that allows for continuous suction. The tube has two lumens; one removes gastric contents and the other serves as an air vent. The vent allows air to enter the stomach, allowing the tube to float freely and preventing damage to the gastric mucosa. D - An Ewald tube is used to irrigate the stomach in cases of active bleeding.

A nurse is providing teaching to a client who has a new prescription for dimenhydrinate to prevent motion sickness. Which of the following instructions should the nurse include? Select all A - Sit upright for 30 min after taking the drug. B - Avoid antacids. C - Take the drug 30 to 60 min before activities that trigger nausea. D - Avoid activities that require alertness. E - Increase fluid and fiber intake.

C - Take the drug 30 to 60 min before activities that trigger nausea. D - Avoid activities that require alertness. E - Increase fluid and fiber intake. Rational A - Sit upright for 30 min after taking the drug is incorrect. Dimenhydrinate, an antihistamine, is unlikely to cause esophagitis, so this precaution is unnecessary. Alendronate, a bisphosphonate that treats osteoporosis, is a drug that requires sitting upright for 30 min after taking it because it can cause esophagitis. B - Avoid antacids is incorrect. Dimenhydrinate does not interact specifically with antacids. Antacids can decrease the absorption of ranitidine, another GI-system drug. C - Take the drug 30 to 60 min before activities that trigger nausea is correct. The nurse should instruct the client to take dimenhydrinate 30 to 60 min before activities that trigger nausea, and again before meals and at bedtime. D - Avoid activities that require alertness is correct. Dimenhydrinate can cause sedation. The nurse should instruct the client to avoid activities that require alertness. E - Increase fluid and fiber intake is correct. Dimenhydrinate can cause anticholinergic effects, such as dry mouth and constipation. The nurse should instruct the client to increase activity level, and fluid and fiber intake.

A nurse is assisting with the admission of a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? A - Famotidine B - Esomeprazole C - Vasopressin D - Omeprazole

C - Vasopressin Rational A - Famotidine is an H2 receptor antagonist used to treat stress ulcers. B - Esomeprazole is a proton pump inhibitor used to treat gastrointestinal reflux disease. C - Vasopressin constricts the splanchnic bed and decreases portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varices. D - Omeprazole is a proton pump inhibitor used to treat duodenal and gastric ulcers.

Nasogastric tube feedings are an appropriate choice for a patient who A -has a paralytic ileus. B - has recently experienced facial trauma. C - is postoperative following laryngectomy. D - has pancreatitis.

C - is postoperative following laryngectomy. Rational A - A patient with a paralytic ileus has absence of gastrointestinal motility. Therefore, this is not an appropriate choice for the patient. B - Due to the high risk of improper tube placement, patients with recent facial or nasal trauma should not have a nasoenteric tube placed. These patients are better candidates for surgical placement of a gastric or jejunal tube. C - Immediately following removal of the larynx, patients typically receive IV fluids or parenteral nutrition until the gastrointestinal tract recovers from anesthesia. Then, a nasogastric tube is inserted and left in place for about 7 to 10 days to provide enteral feedings until swallowing is safe and adequate. D - Pancreatitis is inflammation of the pancreas; therefore, food and fluids are withheld to allow the pancreas to rest and reduce pancreatic secretion.

The most reliable method for verifying initial placement of a small-bore feeding tube is by A - measuring the pH of gastric aspirate. B -auscultating the epigastric area while injecting air. C - obtaining an abdominal x-ray. D - placing the open end of the tube in a cup of water.

C - obtaining an abdominal x-ray. Rational A- Stomach contents are normally acidic, usually with a pH from 1 to 4. A pH above 6 is an indication that the distal end of the tube could be in the respiratory tract or in the intestines. Measuring pH is an acceptable method, but it is not the most reliable method for confirming gastric placement. B - Auscultation is no longer considered a valid method of determining tube placement. C - This is the most reliable method for verifying initial placement of a small-bore feeding tube. D - Persistent bubbling might indicate that the tube has passed through the larynx into the trachea, but it is not the most reliable method for confirming gastric placement.

A nurse is caring for a client who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied. Which of the following statements by the nurse is appropriate? A - "Let me provide more stimulation in his environment." B - "I will call the doctor and get the prescription." C- "I will cover the catheter so he cannot see it." D - "Let's wait until tonight to see if he continues this behavior."

C- "I will cover the catheter so he cannot see it." Rational A - The nurse should reduce environmental stimuli to attempt to decrease the client's agitation and confusion. B - The nurse should try alternative interventions before applying restraints. C - Using stockinette or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the client's attention away from the catheter. D - Due to concerns about the client's safety, the nurse should not delay addressing the situation.

A nurse is reinforcing teaching about nutrition with a parent of an infant. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should start solid foods when my baby is 3 months old." B. "I should introduce cow's milk when my baby is 9 months old." C. "I should wait to give my baby fruit juice until 6 months of age." D. "I should offer my baby well-cooked table foods at 8 months of age."

C. "I should wait to give my baby fruit juice until 6 months of age." Rational A - The parent should introduce solid foods between 4 and 6 months of age. B - Cow's milk lacks the nutrients an infant needs to grow. The parent should introduce cow's milk after the infant is 12 months old. C - Fruit juice provides minimal nutritional value to the infant's diet. Therefore, the parent should limit the infant's fruit juice intake and not offer it until 6 months of age. D - The parent should introduce well-cooked table foods after the infant is 12 months old and has the ability to chew adequately.

A nurse is caring for a client who came to the emergency department with abdominal distension and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client reports anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority? A. Request a prescription for a medication to ease to client's anxiety B. Irrigate the NG tube with 100 mL of sterile water C. Check to see if the suction equipment is working D. Remove and reinsert the NG tube

C. Check to see if the suction equipment is working Rational A - It might become necessary to request an anti-anxiety medication to calm the client, but this is not the first action the nurse should take. B - It might become necessary to irrigate the tube to restore its patency, but this is not the first action the nurse should take. C - The first action the nurse should take using the nursing process is to collect data. The nurse should check for the most obvious reason why the client's symptoms have returned. If the suction equipment has malfunctioned, the nurse should adjust it or replace it with working equipment. D - It might become necessary to remove and replace the tube if the tube becomes irreparably obstructed, but this is not the first action the nurse should take.

A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take? A. Keep the formula cold until instillation B. Withhold the feeding if the residual volume is 150 mL C. Cleanse the top of the can of formula with an alcohol wipe D. Flush the tube with 30 mL of sterile water before the feeding

C. Cleanse the top of the can of formula with an alcohol wipe Rational A - The formula should be at room temperature when the nurse instills it. If the formula is cold, it can cause gastric cramping, nausea, and vomiting. B - The nurse should withhold the feeding if the residual volume exceeds 500 mL to help prevent aspiration. C - Surface bacteria and dust can contaminate the top of formula cans, so the nurse should disinfect them before opening them and introducing contaminants into the formula. They should air-dry before opening to avoid introducing alcohol into the formula. D - The nurse should flush the tube with 30 mL of water after feeding to help keep the tube patent.

A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care? A. Measure abdominal girth daily B. Use sterile water to irrigate the nasogastric tube C. Maintain the client in Fowler's position D. Moisten the client's lips with lemon-glycerin swabs

C. Maintain the client in Fowler's position Rational A - An increase in abdominal girth indicates that the client's abdominal distension has increased. The nurse should measure the client's abdominal girth every 4 to 8 hr. B - To preserve the client's electrolyte balance, the nurse should use 0.9% sodium chloride to irrigate the nasogastric tube. C - The nurse should place the client in Fowler's position to reduce pressure on the diaphragm and to promote function of the nasogastric tube. D - The nurse should avoid using lemon-glycerin swabs because they cause drying of the lips. The nurse should use a water-soluble lip lubricant to moisten the client's lips.

A nurse is contributing to the plan of care of a client who has acute pancreatitis. Which of the following interventions should the nurse include in the plan? A. Provide frequent small snacks B. Ambulate the client twice daily C. Monitor urine output hourly D. Encourage deep breathing and coughing every 2 hr

C. Monitor urine output hourly Rational A - The nurse should recognize that the client who has pancreatitis is made NPO and not given anything by mouth. The rationale behind this is to allow the pancreas to rest and minimize additional damage caused by pancreatic secretions. B - The nurse should recognize that clients who have acute pancreatitis are placed on bed rest to minimize metabolic activity, decrease intestinal irritation caused by movement, and help control pain. C - The nurse should recognize that the client who has pancreatitis is at increased risk for acute kidney injury resulting from decreased cardiac output. This manifests as a urine output of less than 30 mL/hr, which should be reported to the provider. D - The nurse should identify the client who has pancreatitis as being at risk for atelectasis and pneumonia due to bed rest and shallow breathing because of the abdominal pain. Coughing and deep breathing should be done every hour to improve ventilation and mobilize secretions.

A nurse is caring for a client who has a new prescription for ranitidine to treat GERD. The nurse should instruct the client to wait at least 1 hr between taking ranitidine and which of the following over-the-counter drugs? A - Ginkgo biloba B - Antidiarrheals C - St. John's wort D - Antacids

D - Antacids Rational A - Ginkgo biloba does not specifically interact with ranitidine, a histamine2-receptor antagonist. It can, however, decrease drug levels of omeprazole, another GI-system drug. B - Antidiarrheal preparations do not specifically interact with ranitidine, a histamine2-receptor antagonist. However, bismuth subsalicylate, which is used to treat diarrhea, can decrease the absorption of tetracycline and quinolones. C - St. John's wort does not specifically interact with ranitidine, a histamine2-receptor antagonist. It can, however, decrease drug levels of omeprazole, another GI-system drug. D - Antacids can decrease the absorption of ranitidine, a histamine2-receptor antagonist. The nurse should instruct the client to wait at least 1 hr between taking ranitidine and taking an antacid.

A nurse is collecting data from a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect? A - Decreased heart rate B - Yellowing of the skin C - Increased blood pressure D - Boardlike abdomen

D - Boardlike abdomen Rational A - The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of shock, including tachycardia. B - The nurse should expect a client who has liver disease to exhibit jaundice, or yellowing of the skin. C - The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of shock, including hypotension. D - The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of a boardlike abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation also causes hemorrhaging.

A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? A - Vanilla pudding B - Apple juice C - Diet ginger ale D - Clear liquids

D - Clear liquids Rational A - Vanilla pudding contains sugar, which can cause diarrhea due to hyperosmolarity. Clear liquids should be given as the first oral feeding. B - The sugar content of apple juice can cause diarrhea due to hyperosmolarity. Clear liquids should be given as the first oral feeding. C - The client should avoid carbonated beverages because they can distend the stomach, causing pressure on the internal sutures or staples. Pressure can cause leaking into the peritoneum resulting in peritonitis. D - Clear liquids, such as water or broth, can be given for the first oral feedings, but should be limited to only 30 mL (1 oz) per feeding. Water does not contain sugar, which could cause diarrhea due to hyperosmolarity.

A nurse is assisting with the care of a client who is receiving total parenternalnutritoin (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? A - Hypertension B - Excessive thirst C - Fever D - Diaphoresis

D - Diaphoresis Rational A - A client experiencing fluid volume overload will exhibit hypertension. B - A client experiencing hyperglycemia will exhibit excessive thirst. C - A client who has an infection will have an increased temperature. D - The nurse should recognize that the client has the potential for the development of hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger.

A nurse is collecting data from a client who has pancreatitis which of the following should the nurse expect? A - Pain in upper right quadrant radiating to right shoulder B - Report of pain worse when sitting up C - Pain relieved with defecation D - Epigastric pain radiating to the left shoulder

D - Epigastric pain radiating to the left shoulder

A nurse is reviewing the admission lab results of a client who has acute pancreatitis. Which findings would the nurse expect? A - Decreased lipase B - Decreased amylase C - Increased calcium D - Increased glucose

D - Increased glucose Lipase and amylase are elevated

A nurse is caring for a patient who has a nasogastric tube connected to suction. Which of the following should indicate to the nurse that the tube has become occluded? A - Active bowel sounds B - Passing flatus C - Increase in gastric secretions D - Patient's report of nausea

D - Patient's report of nausea Rational A - As peristalsis returns, air and fluid move through the intestines, and bowel sounds become active. B - As peristalsis returns, air and fluid move through the intestines and cause flatus. C - If the tube becomes occluded, secretions will decrease. D - Tubes connected to suction decompress the gastrointestinal tract. This is needed when peristalsis is absent. If gastric secretions are unable to move through the gastrointestinal tract and if the nasogastric tube is unable to evacuate the stomach due to an occlusion, nausea and vomiting will result.

A nurse is caring for a client who is dehydrated and is receiving a continuous tube feeding through a pump at 75 mL/hr. When the nurse checks the client at 0800, which of the following findings requires intervention by the nurse? A - A full pitcher of water sitting on the client's bedside table within the client's reach. B - The disposable feeding bag is from the previous day at 1000 and contains 200 mL of feeding. C - The client is lying on the right side with a visible dependent loop in the feeding tube. D - The head of the bed is elevated 20°.

D - The head of the bed is elevated 20°. Rational A - The nurse should monitor the client's intake and output as well as observe the client for manifestations of dehydration, such as dry mucous membranes, thirst, and decreased urinary output. A pitcher of water at the client's bedside does not require intervention by the nurse. B - The client's feeding bag should be changed every 24 hr. The 200 mL remaining in the bag is sufficient to last until the bag needs to be changed. Because the rate is 75 mL/hr, the nurse will need 150 mL to cover the 2 hr until the bag needs to be changed. The 50 mL left in the bag will ensure that the bag does not run dry, causing air to enter the client's stomach. C - This observation does not require intervention because the feeding is not fed by gravity, but by a pump, and is set at a constant rate. The client's side-lying position will not affect the pump's rate of flow unless the client is lying on the tubing. D - The head of the bed should be elevated at least 30° (semi-Fowler's position) while the tube feeding is administered. This position uses gravity to help the feeding progress down through the digestive system and lessens the possibility of regurgitation.

A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feeding at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions? A. "I will allow the position my mother finds most comfortable during the feeding." B. "I will elevate the head of the bed degrees during the feeding." C. "I will turn my mother on her left side during the feeding." D. "I will position the head of the bed 45 degrees during the feeding."

D. "I will position the head of the bed 45 degrees during the feeding." Rational A - The position the client finds most comfortable might put her at risk for aspiration. B - Although this position is better than having the head of the bed completely flat, it is not optimal for preventing aspiration during enteral feedings. C - Although a side-lying position can help prevent aspiration in some circumstances, such as during oral hygiene and when a client is having a seizure, it is not optimal for preventing aspiration during an enteral feeding. D - The family member should elevate the head of the bed at least 30° and preferably 45° to avoid aspiration during enteral feedings.

A provider prescribes a sublingual medication for a client who has an NG tube in place. Which of the following actions should the nurse take? A. Request a prescription for an oral formulation of the medication B. Administer the crushed medication through the NG tube C. Dissolve the medication in water and give it through the NG tube D. Administer the medication under the client's tongue

D. Administer the medication under the client's tongue Rational A - There is no need for the nurse to request a change in the prescription. B - Depositing a sublingual medication into the stomach exposes it to gastric juices, which can inactivate it. C - Depositing a sublingual medication into the stomach exposes it to gastric juices, which can inactivate it. D - The nurse should administer the sublingual medication under the client's tongue. Sublingual preparations work via direct absorption into the bloodstream. Swallowing it exposes it to gastric juices, which can inactivate it.

A nurse is caring for a client who has a history of pancreatitis. Which of the following food choice should the client avoid? A. Noodles B. Vegetable soup C. Baked fish D. Cheddar cheese

D. Cheddar cheese Rational A - A client who has a history of pancreatitis should avoid foods high in fat. Because noodles are low in fat, they are an appropriate food choice for clients who have pancreatitis. B - A client who has a history of pancreatitis should avoid foods high in fat. Because vegetable soup is low in fat, it is an appropriate food choice for clients who have pancreatitis. C - A client who has a history of pancreatitis should avoid foods high in fat. Because baked fish is low in fat, it is an appropriate food choice for clients who have pancreatitis. D - A client who has pancreatitis should avoid foods high in fat. Because cheddar cheese is high in fat content, the client should avoid this food.

A nurse is preparing to remove an NG tube for a client. Which of the following actions should the nurse take first? A. Disconnect the tube from the wall suction B. Perform hand hygiene and don gloves C. Observe the amount and color of drainage D. Verify provider order to discontinue the tube

D. Verify provider order to discontinue the tube Rational A - One purpose of NG tubes is to provide gastric decompression. The NG tube is connected to suction, which is connected to a canister to collect gastric drainage. Prior to discontinuing the NG tube, the suction should be turned to the off position to prevent damage to the gastric mucosa during removal of the tube. It is important to turn off the suction. However, there is another action the nurse should take first. B - Although it is always necessary to perform hand hygiene and don gloves prior to removal of an NG tube, this is not the priority action. Even before this can be done, the nurse must verify there is a provider order for the removal of the tube. Additionally, neither the insertion nor the removal of a NG tube requires sterile technique, only clean technique. C - One purpose of NG tubes is to provide gastric decompression. The NG tube is connected to suction, which is connected to a canister to collect gastric drainage. Part of the nursing process is to observe and record the color and amount of gastric drainage. It is important to observe the amount and color of gastric drainage. However, there is another action the nurse should take first. D - Discontinuing a NG tube requires a provider order. Therefore, confirmation of an order would be the priority action to take before removal of the tube. Nasogastric tubes can be used to provide enteral nutrition, to administer medication, and to provide gastric decompression.

How long should a patient remain upright after feeding and why?

30-45 min to prevent regurgitation and/or aspiration

a nurse is administering bolus enteral feedings to a client who has malnutrition. Which of the following are appropriate nursing interventions? A - Verify the presence of bowel sounds B - Flush the feeding tube with warm water C - Elevate the HOB 20 degrees D - Administer the feeding at room temp E - Instill the formula over 60 min

A - Verify the presence of bowel sounds B - Flush the feeding tube with warm water D - Administer the feeding at room temp

What method is considered best practice when checking NG tube placement every shift? A - Aspirate content and check pH level B - Check the xray for properplacment. C - Inject air and listen for a "swoosh" sound D - Check chart for record length at the time of insertion.

A - Aspirate content and check pH level

Nurse Karen is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age A - Formula or breast milk B - Dilure nonfat dry milk C - Warmed fruit juice D - Fluoridate tap water

A - Formula or breast milk

Which is not a complication of NG tube insertion A - Hemothorax B - Aspiration C - Sore/Raw throat & Ulcerations to nares D - Pneumothorax

A - Hemothorax

Which of the following statement is incorrect? A - It may be necessary to feed the child every 5 to 7 hours initially B - Delays in reaching developmental milestones, such as rolling over, crawling, and talkin cannot be achieved on time C - Approximately 80% of children with failure to thrive present before 18 months of age D - Failure to thrive had been defined in a number of ways, but most definitions include a weight less than a 5th percentile on the growth chart of a decreasing rate of weight gain.

A - It may be necessary to feed the child every 5 to 7 hours initially

A patient has had colon surgery as a result of an intestinal obstruction. A method of delivering nutrition to avoid the gut would be: A - Total Parenteral Nutrition (TPN) B - Puree diet with thickened liquids C - Tube feedings per gastrostomy tube D - tube feeding per nasogastric (NG) tube

A - Total Parenteral Nutrition (TPN)

NG tube insertion is done for following reason EXCEPT which A - as part of bariatric program B - Decompress the stomach C - Provide feedings, medications D - Treatment of obstruction

A - as part of bariatric program

A nurse inserting a nasogastric tube asks the patient to flex her head toward her chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by A - closing off the glottis. B - preventing curling of the tube in the mouth. C - allowing the patient to breathe through her mouth. D - opening the lower esophageal sphincter.

A - closing off the glottis. Rational A - This action prohibits the tube from entering the trachea. B - Instructing the patient to swallow will reduce discomfort and prevent trauma. C - This action does not facilitate breathing through the mouth. D - Because the tube is passing through the nasopharynx, the esophageal sphincter would not yet be involved.

What is the expected level of gastric pH A - less than 5.5 B - less than 3.0 C - Greater than 6.0 D - Greater than 6.5

A - less than 5.5

What setting is commonly used when suctioning gastric contents? A - low intermittent suction B - Hihg continuous suction C - High intermittent suction D - Medium continuous suction

A - low intermittent suction

What is the "blue" lumen used for on a Salem sump A - ventilation B - Medications C - Suctioning D - Feeding

A - ventilation

A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following as being at risk for hypokalemia? A. An NG tube to suction B. An indwelling urinary catheter to gravity drainage C. A chest tube to water-seal drainage D. A nephrostomy tube to a drainage bag

A. An NG tube to suction Rational A - Hypokalemia is low serum potassium. When connected to a suction source, an NG tube empties the stomach of gastric contents. Gastric contents are high in electrolytes, and losing them puts the client at risk for hypokalemia and other electrolyte imbalances. B - Drainage of urine does not deplete potassium, unless the client is taking a potassium-wasting diuretic, such as hydrochlorothiazide. C - Drainage of air, blood, and fluid from a chest tube does not deplete potassium. D - Drainage of urine does not deplete potassium, unless the client is taking a potassium-wasting diuretic, such as hydrochlorothiazide.

A nurse is collecting data on a client who has acute pancreatitis. Which of the following factors should the nurse anticipate in the client's history? A. Gallstones B. GERD C. Shock D. Diabetes mellitus

A. Gallstones Rational A- The nurse should identify the presence of gallstones as a causative factor in the development of acute pancreatitis. This occurs because a stone blocks the outflow of pancreatic enzymes and bile from the gall bladder and into the duodenum resulting in autodigestion and inflammation of the pancreas. An additional causative factor is excessive use of alcohol. B - The nurse should recognize that complications of GERD include Barrett's esophagus and esophageal cancer. However, GERD is not a contributing factor in the development of acute pancreatitis. C - The nurse should recognize that untreated pancreatitis can lead to shock as a result of the autodigestion of the pancreas and the circulation of the enzymes and cell contents into the general circulation. However, shock is not a contributing factor in the development of acute pancreatitis. D - The nurse should recognize that diabetes can be a complication of chronic pancreatitis. However, diabetes is not a contributing factor in the development of acute pancreatitis.

A nurse is caring for a client who is receiving total parenteral nutrition via an infusion pump. When collecting data about the client receiving this therapy, which of the following factors should the nurse monitor? A. IV insertion site B. Height of the IV pole C. The client's oral intake D. Manifestations of hypoglycemia

A. IV insertion site Rational A - It is essential that the nurse monitor the IV insertion site, generally for a central venous access device for TPN, for signs of infection regardless of the fluid delivery system. B - Since the TPN is infusing via an IV infusion pump, the height of the IV pole is irrelevant. Gravity is not an issue with an infusion pump, which controls the flow of the solution mechanically. C - Generally, providers prescribe TPN for clients who cannot ingest fluids and nutrients orally. D - Clients receiving TPN are at risk for hyperglycemia, not hypoglycemia.

A nurse is reinforcing discharge teaching with a client who has acute pancreatitis and a prescription for fat-soluble vitamin supplements. Which of the following supplements should the nurse include in the teaching? A. Vitamin A B. Vitamin B C. Vitamin C D. Vitamin B12

A. Vitamin A Rational A - The nurse should instruct the client that fat-soluble vitamins include vitamins A, D, E, and K. B- Vitamin B1 is water-soluble vitamin. C - Vitamin C is water-soluble vitamin. D - Vitamin B12 is water-soluble vitamin.

What actions do you never want to do with the blue lumen on a salem sump?

Administer feedings, medications, hook up to suction

What two questions should a patient (or nurse) know about medications prior to putting them into a tube?

That they are safe to crush and if the medication comes in a liquid form (which is preferable for enteral administration)

A nurse is preparing to administer intermittent enteral feedings to a client. Which of the following are appropriate interventions? A - Fill the bag with 24 hours worth of formula B - Discard feeding equipment after 24 hours C Place any unused formula in open cans in the refrigerator D - Flush the feeding tube every 4 hours E - Elevate the head of the bed for 15 minutes after administration

B - Discard feeding equipment after 24 hours C Place any unused formula in open cans in the refrigerator D - Flush the feeding tube every 4 hours

What type of medications should never be crushed A - Blood pressure medication B - Enteric coated, extended or delayed release C - regular tablets D - Anticoagulants and blood thinners.

B - Enteric coated, extended or delayed release

A stroke patient has dysphagia and is at high risk for aspiration. An enteral tube into the small intestine is recommended by the surgeon. Which would be placed into the intestine? A - Gastrostomy tube B - Jejunostomy tube C - Percutaneous endoscopic gastrostomy tube (PEG) D - Nephrostomy tube

B - Jejunostomy tube - do not need to check for residual - going into the intestine

What is the purpose of elevated the head during NG feeding or med administration? A - Helps with digestion B - Prevents aspiration C - Ease of instilling food or meds D - Comfort for the patient

B - Prevents aspiration

When inserting an NG, what action is taken, when the pt begins to cough and have difficult breathing? A - Stop and wait until the respiratory distress subsides B - Removes the tube and reinsert when distress subsides. C - Quickly insert the tube D - Notify the charge nurse or physician

B - Removes the tube and reinsert when distress subsides.

A nurse is providing teaching to a client who has a new prescription for omeprazole to treat a duodenal ulcer. Which of the following instructions should the nurse include? A - Take the drug with food. B - Swallow the capsules whole. C - Dissolve the tablets in water. D - Take the drug at bedtime.

B - Swallow the capsules whole Rational A- Food can reduce the absorption of omeprazole, a proton pump inhibitor. Clients should take the drug 1 hr before a meal. B - Omeprazole, a proton pump inhibitor, is unstable in stomach acid. The nurse should tell the client to swallow the capsules or tablets whole and not chew the delayed-release tablets. C - Omeprazole, a proton pump inhibitor, is available in delayed-release tablets or capsules, and in an immediate-release powder mixed with water for oral dosing. If taking the tablet formulation, the client should swallow them whole. Ranitidine is a GI-system drug that is available in effervescent tablets to dissolve completely in water before swallowing. D - Omeprazole, a proton pump inhibitor, decreases the secretion of gastric acid. It is most effective when clients take it in the morning prior to the first meal of the day.

Small bore NG tubes should never be used for A - administering fluids B - suctioning gastric content C - administering medication D - feeding a patient.

B - suctioning gastric content

A nurse is contributing to the plan of care prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take? A. Flush the tube with sterile sodium chloride solution every 2 hr B. Change the feeding bag every 24 hr C. Check the gastric residual every 8 hr D. Position the head of the client's bed at 15 degrees

B. Change the feeding bag every 24 hr Rational A - The nurse should flush the client's tube after each residual check, and before and after providing medication, using water. Administering saline solution frequently could cause hypernatremia. B - The nurse should change the feeding bag every 24 hr to minimize the potential for bacterial colonization. C - The nurse should plan to check the gastric residual every 4 to 6 hr. D - The nurse should position the head of the client's bed at 30° to 45°.

A nurse is reviewing the laboratory values of a client who is receiving total parenteral nutrition (TPN): glucose 72 mg/dL, chloride 100 mEq/L, and potassium 3.0 mEq/L. Which of the following actions should the nurse plan to take? A. Discontinue the TPN infusion B. Request a potassium replacement C. Administer glucagon IM D. Check the client for a positive Chvostek's sign

B. Request a potassium replacement Rational A - If indicated, the nurse should taper TPN gradually to prevent hypoglycemia, or alterations in fluid and electrolyte levels. B - This potassium level is below the expected reference range. Therefore, the nurse should initiate cardiac monitoring and request a potassium replacement. C - The nurse should plan to administer glucagon IM to a client who has hypoglycemia and is unable to take oral glucose. D - The nurse should check for Chvostek's sign for a client suspected to have hypocalcemia or hypomagnesemia.

You need to administer medication via the NG tube that is attached to suction. What do you do? A - Reposition the client to assist in absorption B - Change suction setting to low intermittent C - Clamp the NG for 30-60 min following administration D - Aspirate NG tube after administration to maintain patency

C - Clamp the NG for 30-60 min following administration

Nurse Karen is teaching the mother on how to take care of her child who is experience failure to thrive. The mother would not be correct in saying A - "I will feed the child slowly and carefully in a quiet environment" B - "I will burp the child frequently during and at the end of each feeding." C - "I will talk to the child in a loud and booming way so that he could be stimulated and respond accordingly" D - "I will carefully document food intake and caloric intake and strict intake and output records"

C - "I will talk to the child in a loud and booming way so that he could be stimulated and respond accordingly"

What is the most accurate way to confirm correct placement? A - Listen for the "whoosh" of air B - Abdominal ultrasound C - Abdominal x-ray D - Brain CT

C - Abdominal x-ray

Mrs. Bayer tells nurse Karen that she is very worried because her 2-year old child does not finish his meals. What should Karen advice the mother? A - Make the child seat with the family in the dining room until he finished his meal B - Provide a quiet environment for the child before meals C - Do not give snacks to the child before meals D - Put the child on a chair and feed him

C - Do not give snacks to the child before meals

What task is important to perform before and after using an NG tube A - FLush the tube with 30 mL of air B - Flush the tube with Diet coke C - Flush the tube with tap water D - Flush the tube with normal saline

C - Flush the tube with tap water

What may happen if an NG tube is not flushed regularly A - Nothing will happen, it's not required B - It could get stuck on side of stomach C - It may become blocked D - It can cause burning and skin breakdown

C - It may become blocked

PEG is an abbreviation for A - Peritoneal entering gastrostomy B - Positive endoscopic gastric C - Percutaneous endoscopic gastrostomy D - Pretty entertaining gal

C - Percutaneous endoscopic gastrostomy

A large bore NG tube is often called A - Levine tube B - Button tube C - Salem sump D - Triple lumen

C - Salem sump

A nurse is collecting data from a client who is receiving intermittent enteral feedings. Which of the following laboratory values should the nurse identify as an indication that the client needs a change in the formula? A. Hematocrit 42% B. Urine specific gravity 1.022 C. BUN 28 mg/dL D. Sodium 142 mEq/L

C. BUN 28 mg/dL Rational A - A hematocrit of 42% is within the expected reference range. B - A urine specific gravity of 1.022 is within the expected reference range. C - A BUN of 28 mg/dL is above the expected reference range. It indicates dehydration and requires a change in the formula to increase the intake of water. D - A sodium level of 142 mEq/L is within the expected reference range.

A nurse is contributing to plan of care of a client who has a small bowel obstruction. Which of the following interventions should the nurse include? A. Measure abdominal girth daily B. Provide bulk-forming agent C. Elevate the head of the bed D. Monitor intake and output every 8 hr

C. Elevate the head of the bed Rational A- The nurse should measure abdominal girth every 4 to 8 hr to monitor the development of further intestinal obstruction B - The nurse should not expect to administer a bulk forming agent to the client who has a small bowel obstruction, since this may cause further blockage, nausea, and vomiting. C - The nurse should elevate the head of the bed to relieve pressure on the diaphragm and ease breathing in the client who has a bowel obstruction. D - The nurse should monitor intake and output every 2 to 4 hr to monitor the hemodynamic stability of the client. The fluids removed through the nasogastric tube along with the NPO status of the client can lead to hypovolemia.

A nurse is preparing to administer a bolus enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take first? A. Measure stomach contents B. Flush the tube with water C. Elevate the head of the bed D. Return gastric content into the gastrostomy tube

C. Elevate the head of the bed Rational A - The nurse should measure the stomach contents to determine whether the stomach is emptying and prevent overfeeding; however, there is another action the nurse should take first. B - The nurse should flush the tube with water to maintain tube patency; however, there is another action the nurse should take first. C - The greatest risk to the client is injury from aspiration; therefore, the first action is to elevate the client's head of bed into high-Fowler's position, or at least 30° to 45°. D - The nurse should return gastric contents into the gastrostomy tube to prevent electrolyte imbalance; however, there is another action the nurse should take first.

A nurse is preparing to administer enteral feeding via an established NG tube. Identify the sequence the nurse should follow to initiate the feeding. A. Check the residual feeding contents B. Evaluate tolerance to the feeding C. Verify tube placement D. Administer the feeding

C. Verify the placement A. Check the residual feeding contents D. Administer the feeding B. Evaluate tolerance to the feeding Rational The first action the nurse should take is to verify tube placement. Next, the nurse should check the residual feeding contents and follow agency protocol about re-instilling the contents into the stomach. Then, the nurse should administer the feeding, followed by an evaluation of the client's tolerance to the feeding.

A nurse is inserting an NG tube. Identify the sequence the nurse should follow. A. Lubricate the tube B. Measure tube for placement C. Place client in high-Fowler's position D. Advance tube downward and backward E. Insert tube along the base of nares F. Check position of the tube and secure

C. Place client in high-Fowler's position B. Measure tube for placement A. Lubricate the tube E. Insert tube along the base of nares D. Advance tube downward and backward F. Check position of the tube and secure Rational ​Place the client in high Fowler's position because it promotes the client's ability to swallow during the procedure. The nurse should also raise the bed to promote good body mechanics and prevent injury to herself.The nurse should measure the tube in order to know how far to advance the tube. When determining placement length, the nurse should measure the distance from the tip of the nose to earlobe to xiphoid process. The nurse should mark the tube as an indication of how far to advance to the stomach.The nurse should lubricate 7.5 to 10 cm (4 to 6 in) of the end of the tube with water-soluble lubricating jelly. This minimizes friction against the nasal mucosa and aids insertion of the tube. The nurse should insert the tube along the base of the nares to minimize the discomfort of the tube rubbing against the upper nasal turbinates.The nurse should advance the tube downward and backward. Downward pressure helps the tube curl around the corner of the nasopharynx. Backward motion aligns the tube with the nasopharynx structures. This also helps prevent coiling of the tube in the oropharynx. With the tube just above the oropharynx, the nurse should instruct the client to flex head forward, take a small sip of water, and swallow. The nurse should advance the tube 2.5 to 5 cm (1 to 2 in) with each swallow. The flexed position closes off the upper airway to the trachea and opens the esophagus. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Swallowing water reduces gagging or choking. If the client begins to cough, gag, or choke, the nurse should withdraw the tube slightly and stop tube advancement. The nurse should instruct the client to breathe easily and take sips of water.The nurse should check the position of the tube according to agency policy and then secure it.

A nurse is caring for a client and is preparing to insert a large bore NG tube. Identify the order of the steps the nurse should perform. A. Lubricate the tip of the tube B. Obtain an x-ray C. Place the tube in a basin of warm water D. Measure how far to insert the tube E. Insert the tube

C. Place the tube in a basin of warm water D. Measure how far to insert the tube A. Lubricate the tip of the tube E. Insert the tube B. Obtain an x-ray Rational First, the nurse should place the tube in a basin of warm water. Placing the tube in a basin of warm water will make the tube more pliable and flexible, facilitating insertion. Next, the nurse should measure how far to insert the tube. The nurse should determine how far to insert the tube by measuring the tubing from the tip of the nose, to the tip of the ear lobe, to the tip of the xiphoid, and mark the place with adhesive tape. The next step is to lubricate the tip of the tube. The nurse should lubricate the tube with a water-soluble gel or water to facilitate passing the tube through the nares. Using an oil-based lubricant can result in respiratory complications as it does not dissolve. After lubricating the tip of the tube, the nurse should insert the tube. The nurse should ask the client to extend his neck back against the pillow to facilitate the initial passage of the tube. The nurse should gently insert the tube slowly, aiming the end of the tube downward. When the nurse has advanced the tube to just above the oropharynx, the nurse should instruct the client to flex the head forward, take a sip of water, and swallow. The flexed position closes off the upper airway to the trachea and opens the esophagus. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Swallowing water reduces gagging or choking. Sipping of the water also aids passage of the NG tube into the esophagus. The last step is to obtain an x-ray. The nurse should verify placement after inserting the NG tube. The nurse should ask the client to talk, inspect the posterior pharynx for coiled tubing, aspirate gastric contents and observe the color, test the pH of gastric contents (a pH of 4 or less is expected), and confirm placement with an x-ray (this is the most accurate method to verify placement).

How many ports are available on an NG tube A - 3 B - 1 C - 4 D - 2

D - 2

Nurse Karen is assessing a child's cultural background, Karen should keep in mind that A - Cultural background usually has little bearing on a family's health practices. B - Physical characteristics mark the child as part of a particular culture C - Heritage dictates a group's shared values D - Behavioral patterns are passed from one generation to the next.

D - Behavioral patterns are passed from one generation to the next.

What position should a patient be in when receiving feedings A - Prone B - Supine C - Trendelenburg D - Fowlers

D - Fowlers

A small bore nasogastric tube is known as A - PEG B - Stomach tube C - PICC D - NG tube or NGT

D - NG tube or NGT

Can an NG tube be used immediately after insertion A - Yes B - Depends on situation C - I don't know D - No

D - No

A PEG tube is ________ placed and held in position by _______________ A - Surgically , staples B - Medically, inflated balloon C - Medically, stitches D - Surgically, inflated balloon

D - Surgically, inflated balloon

To determine how much of the length of a nasoenteric tube to insert, a nurse should measure the distance from the tip of the patient's nose to the earlobe and from the earlobe to the A- umbilicus. B - xiphoid process. C - manubrium plus 10 to 20 cm more. D - xiphoid process plus 20 to 30 cm more.

D - xiphoid process plus 20 to 30 cm more. Rational A - Measuring from the tip of the nose to the earlobe to the umbilicus would exceed the recommended length of feeding tube to be inserted. B - Measuring from the tip of the nose to the earlobe to the xiphoid process only approximates the distance from the nose to the stomach. C - Measuring from the tip of the nose to the earlobe to the manubrium and adding 10 to 20 cm would underestimate the recommended length of feeding tube to be inserted. D - Measuring from the tip of the nose to the earlobe to the xiphoid process approximates the distance from the nose to the stomach for 98% of patients. For duodenal or jejunal placement, an additional 20 to 30 cm is required.

A nurse is contributing to the plan of care for a client who has a gastrostomy tube through which he is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan? A. Change the feeding bag and tubing every 72 hr B. Keep the head of the bed elevated at 15 degrees C. Place enough formula in the feeding bag to last for 8 hr of continuous feeding D. Flush the tube with 30 mL of water every 4 hr

D. Flush the tube with 30 mL of water every 4 hr Rational A - The nurse should change the feeding bag and tubing every 24 hr to limit the growth of bacteria within the system. B - The nurse should elevate the head of the bed to 45 degrees (semi-Fowler's position) for a client who is receiving continuous enteral feedings to limit the risk of aspiration of the formula. C - The nurse should limit the quantity in the feeding bag to provide feeding for a 4 hr time frame to limit bacterial growth within the system. D - The nurse should flush the gastrostomy tube with 30 to 60 mL of water every four hours to provide free water to the client and prevent dehydration.

The nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube. Which of the following interventions should the nurse take when inserting the nasogastric tube? A. Place the client in a supine position B. Measure the tube for insertion from the tip of the nose to the umbilicus C. Withdraw the tube if the client gags during insertion D. Instruct the client to place his chin to his chest and swallow

D. Instruct the client to place his chin to his chest and swallow Rational A - The nurse should place the client in a high Fowler's position to assist with the placement and avoid inserting the tube into the bronchus. B - The nurse should measure the length of tubing for insertion by holding the tip of the tube at the client's nose and extend the tube to the earlobe and then to the distal sternum. C - The nurse should pause with insertion if the client gags and should check the oropharynx to ensure the tubing is not coiled at the back of the throat, but the nurse should not remove the tubing. This creates more trauma for the client. D - The nurse should instruct the client to place his chin to his chest and swallow to facilitate insertion of the nasogastric tube after it reaches the oropharynx. This position directs the tube toward the posterior pharynx and esophagus rather than the larynx and the bronchus.

A nurse is contributing to the plan of care for a client who has acute pancreatitis. Which of the following interventions should the nurse include? A. Monitor peripheral pulses every 8 hr B. Measure urine output every 4 hr C. Ambulate the client three time daily D. Maintain NPO status

D. Maintain NPO status Rational A- The nurse should monitor the client's peripheral pulses, skin color, temperature and turgor every 1 to 2 hr for the client who is acutely ill with pancreatitis as this gives an indication of decreased cardiac output which is a complication of acute pancreatitis. Once the client is stabilized, assessments can be completed every 4 hr. B - The nurse should monitor the client's urine output hourly. Urinary output of less than 30 mL/hr may indicate decreased cardiac output and increase the risk for acute kidney injury. C - The client who has acute pancreatitis has increased pain with stretching of the peritoneum that would occur with activity. The client maintains bed rest during the acute stages of pancreatitis. D - ​To rest the pancreas and reduce secretion of pancreatic enzymes, oral fluids and food are withheld during the acute phase of pancreatitis.

A nurse is caring for a client who has paranoid delusions and believes the hospital food is being poisoned by the staff. Which meal presentation should the nurse consider to be an effective method of encouraging? A. Serve warm foods that arrive from the kitchen with lids in place B. Serve the client's favorite foods in an attractive arrangement C. Serve the same food that other clients in the dining room are eating D. Serve individual items that have sealed packaging

D. Serve individual items that have sealed packaging Rational A- This strategy will not address the issue of poisoning. B - This type of meal will not encourage the client to eat. C - This meal will not address the client's fear of being poisoned. D - A client who fears poisoning will be more likely to eat a meal that comes in sealed containers. The client must feel that the meal is safe and has not been tampered with.

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding? A. Warm the feeding solution to body temperature B. Assist the client to low Fowler's position C. Discard any residual gastric contents D. Test the pH of gastric aspirate

D. Test the pH of gastric aspirate Rational A- The enteral formula should be at room temperature, not body temperature. B - The optimal position for enteral feeding is high Fowler's, not low Fowler's. C - Unless the volume of aspirated gastric contents is more than 100 mL or the facility has different guidelines in place, the nurse should return the aspirate to the client's stomach. D - Before administering enteral feedings, the nurse should verify the placement of the NG tube. The only reliable method is x-ray confirmation, which is impractical prior to every feeding. Testing the pH of gastric aspirate is an acceptable method between x-ray confirmations.

What types of medications should NEVER be crushed?

Enteric coated or sustained release. EC, XR, SR, or ER. These medications are coated to prevent rapid absorption in the body. The coating slowly wears away allowing for a gradual release of the medication over many hours.

What task is important to do before and after using a nasogastric tube and why?

FLUSHING It cleans the tube of leftover tube feedings solution or medications and prevents clogging It helps prevent dehydration is the patines if NPO

Small bore NG tubes are meant for. ___________________ and should never be used for _____________________

Small are meant for tube feeding NOT for suctioning

A PEG is considered a long term solution to feedings TRUE/FALSE

TRUE

A salem sump can be used for feeding or suctioning? TRUE/FALSE

TRUE

True/False A PEG tube must be surgical placed into the stomach?

TRUE

With small bore tubes that are inserted with a guidewire, why is it important to NOT remove the guide wire prior to the X Ray being taken?

The guide wire helps confirm placement in the stomach

True/False A NG tube can be inserted in an unconscious pt

True

True/False You should wear gloves when working with an NG tube

True

What labs are elevated for pancreatitis

amylase lipase WBC Glucose

What is the expected level of gastric pH? What is the intestinal pH level?

gastric - under 5 intestinal - greater than 7

Medications to help decrease gastric acid secretions

ranitidine/Zantac omeprazole/Prilosec