Prep U--Chapter 44: Digestive and Gastrointestinal Treatment Modalities (Med Surg)

As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach? 4 6 8 10

4 Gastric secretions are acidic and have a pH ranging from 1 to 5. Intestinal aspirate is typically 6 or higher; respiratory aspirate is more alkaline, usually 7 or greater.

A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use? 5-mL 10-mL 20-mL 30-mL

30-mL When small-bore feeding tubes for continuous tube feedings are used and irrigated after administration of medications, a 30-mL or larger syringe is necessary, because the pressure generated by smaller syringes could rupture the tube.

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

42 The client's weight of 154 pounds is equal to 70 kg. The client is to receive 0.6 g of protein for each 1 kg of body weight. 0.6 g/kg x 70 kg = 42 grams.

The nurse is to insert a postpyloric feeding tube. How can the nurse aid in placement of the tube past the pylorus? Administer prescribed metoclopramide. Have the client lay on the left side. Assist the client to drink 8 ounces of water. Instruct the client to swallow several times.

Administer prescribed metoclopramide. Metoclopramide (Reglan) is administered to increase peristalsis of the feeding tube into the duodenum. Placing the client on the right side, not the left side, helps to facilitate movement and placement. Having the client swallow or even to drink water facilitates placement of the tube past the epiglottis, not into the duodenum.

A nurse is caring for a client with a long-term central venous catheter. Which care principle is correct?

Clean the port with an alcohol pad before administering I.V. fluid through the catheter.

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take? Remove the tape from the nose of the client. Withdraw the tube gently for 6 to 8 inches. Provide oral hygiene. Flush with 10 mL of water.

Flush with 10 mL of water. Before a nasogastric tube is removed, the nurse flushes the tube with 10 mL of water or normal saline to ensure that the tube is free of debris and away from the gastric tissue. The tape keeps the tube in the correct position while flushing is occurring and is then removed from the nose. The nurse then withdraws the tube gently for 6 to 8 inches until the tip reaches the esophagus, and then the remainder of the tube is withdrawn rapidly from the nostril. After the tube is removed, the nurse provides oral hygiene.

A patient receiving tube feedings has prescriptions for several drugs. Which of the following drugs would the nurse expect to administer to the patient without any special preparation? Select all that apply.

Liquid stool softener Sublingual nitroglycerin

The nurse cares for a client who receives continuous enteral tube feedings and who is at low risk for aspiration. The nurse assesses the gastric residual volume to be 350 mL. The nurse determines which action is correct? Monitoring the feeding closely. Increasing the feeding rate. Lowering the head of the bed. Flushing the feeding tube.

Monitoring the feeding closely. High residual volumes (>200 mL) should alert the nurse to monitor the client more closely. Increasing the feeding rate will increase the residual volume. Lowering the head of the bed increases the client's risk for aspiration.

The nurse is caring for a client who has a gastrostomy tube feeding. Upon initiating care, the nurse aspirates the gastrotomy tube for gastric residual volume (GRV) and obtains 200 mL of gastric contents. What is the priority action by the nurse? Discontinue the infusion. Place the client in a semi-Fowler's position with the head of the bed at 45 degrees. Remove the aspirated fluid and do not reinstill. Dilute the gastric tube feeding solution with water and continue the feeding.

Place the client in a semi-Fowler's position with the head of the bed at 45 degrees. Feedings and medications should always be administered with the client in the semi-Fowler's position, and the client's head should be elevated at least 30 to 45 degrees to reduce the risk of reflux and pulmonary aspiration. This position is maintained at least 1 hour after completion of an intermittent tube feeding and is maintained at all times for clients receiving continuous tube feedings.

A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. The nurse does all of the following. Select all that apply.

Places a 1.5-micron filter on the tubing Ensures completion of baseline monitoring of the complete blood count (CBC) and chemistry panel Ensures availability of an infusion pump

The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length? A length of 50 cm (20 in) A point that equals the distance from the nose to the xiphoid process The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process The distance determined by measuring from the tragus of the ear to the xiphoid process

The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process Before inserting the tube, the nurse determines the length that will be needed to reach the stomach or the small intestine. A mark is made on the tube to indicate the desired length. This length is traditionally determined by (1) measuring the distance from the tip of the nose to the earlobe and from the earlobe to the xiphoid process, and (2) adding up to 15 cm (6 in) for NG placement or at least 20 to 25 cm (8 to 10 in) or more for intestinal placement.

What type of feedings should be administered to a client who is at risk of diarrhea due to hypertonic feeding solutions? continuous feedings intermittent feeding bolus feeding cyclic feeding

continuous feedings Continuous feedings should be administered to a client who is at risk of diarrhea due to hypertonic feeding solutions. Bolus or intermittent feedings cause sudden distention of the small intestine, and cyclic feedings are not advised.

A nurse is caring for a patient receiving parenteral nutrition at home. The patient was discharged from the acute care facility 4 days ago. Which of the following would the nurse include in the patient's plan of care? Select all that apply.

• Intake and output monitoring • Calorie counts for oral nutrients • Daily weights

A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and would make a recommendation when noticing which circumstance? No land line; cell phone available and taken by family member during working hours Water of low pressure that can be obtained through all faucets Little food in the working refrigerator Electricity that loses power, usually for short duration, during storms

No land line; cell phone available and taken by family member during working hours A telephone is necessary for the client receiving PN for emergency purposes. Water, refrigeration, and electricity are available, even if the circumstances are not optimal.

The primary source of microorganisms for catheter-related infections are the skin and which of the following? Catheter hub Catheter tubing IV fluid bag IV tubing

Catheter hub The primary sources of microorganisms for catheter-related infections are the skin and the catheter hub. The catheter site is covered with an occlusive gauze dressing that is usually changed every other day.

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

Wipes catheter ports from distal end to insertion site

The nurse recognizes that medium-length nasoenteric tubes are used for: decompression. feeding. aspiration. emptying.

feeding. Placement of the tube must be verified prior to any feeding. A gastric sump and nasoenteric tube are used for gastrointestinal decompression. Nasoenteric tubes are used for feeding. Gastric sump tubes are used to decompress the stomach and keep it empty.

The nurse conducts discharge education for a client who is to go home with parenteral nutrition (PN). The nurse determines the client understands the education when the client indicates a sign and/or symptom of metabolic complications is: loose, watery stools. increased urination. elevated blood pressure. decreased pulse rate.

loose, watery stools. When the client indicates that loose, watery stools are a sign/symptom of metabolic complications, the nurse evaluates that the client understands the teaching of metabolic complications. Signs and symptoms of metabolic complications from PN include neuropathies, changes in mental activity, diarrhea, nausea, skin changes, and decreased urine output.

Which venous access device can be used for less than 6 weeks in clients requiring parenteral nutrition? nontunneled catheters peripherally inserted central catheters tunneled catheters implanted ports

nontunneled catheters The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored, and it allows the client freedom of movement. It also provides easy access to the dressing site. Peripherally inserted central catheter (PICC) lines may be used for intermediate terms (3 to 12 months). Tunneled central catheters are for long-term use and may remain in place for many years. Implanted ports are devices used for long-term home IV therapy (e.g., Port-A-Cath, Mediport, Hickman Port, P.A.S. Port).

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

Basilic vein Peripherally inserted central catheters are inserted using the basilic or cephalic veins above the antecubital space. The subclavian vein is used for nontunneled central catheters. The jugular vein is used for nontunneled central catheters only as a last resort. The metacarpal vein is used for routine intravenous therapy.

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

continuous feedings Continuous feedings should be administered to a client who is at risk of diarrhea due to hypertonic feeding solutions. Bolus or intermittent feedings cause sudden distention of the small intestine, and cyclic feedings are not advised.

Which condition is caused by improper catheter placement and inadvertent puncture of the pleura? air embolism pneumothorax sepsis fluid overload

pneumothorax A pneumothorax is caused by improper catheter placement and inadvertent puncture of the pleura. Air embolism can occur from a missing cap on a port. Sepsis can be caused by the separation of dressings. Fluid overload is caused by fluids infusing too rapidly.

The nurse is caring for a comatose patient and administering gastrostomy feedings. What does the nurse understand is the reason that gastrostomy feedings are preferred to nasogastric (NG) feedings in the comatose patient? Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. Digestive process occurs more rapidly because the feedings do not have to pass through the esophagus. Feedings can be administered with the patient in the recumbent position. The patient cannot experience the deprivational stress of not swallowing.

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely.

A client with a gastrojejunostomy is beginning to take solid food. Which finding would lead the nurse to suspect that the client is experiencing dumping syndrome? Dry skin Slowed heart beat Diarrhea Hyperglycemia

Diarrhea Clients with a gastrojejunostomy are at risk for developing the dumping syndrome when they begin to take solid food. This syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramps, and diarrhea, which result from the rapid emptying (dumping) of large amounts of hypertonic chyme (a liquid mass of partly digested food) into the jejunum. This concentrated solution in the gut draws fluid from the circulating blood into the intestine, causing hypovolemia. The drop in blood pressure can produce syncope. As the syndrome progresses, the sudden appearance of carbohydrates in the jejunum stimulates the pancreas to secrete excessive amounts of insulin, which in turn causes hypoglycemia.

A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely? Excess fluid volume Risk for imbalanced nutrition, more than body requirements Deficient fluid volume Impaired urinary elimination

Excess fluid volume The patient's intake and output record reflects a greater intake than output, suggesting excess fluid volume. No information suggests that the patient's nutritional balance is at risk, even with nasogastric tube feedings. Deficient fluid volume would be appropriate if the patient's output exceeded input. No information indicates that the patient is experiencing difficulty with urination.

The patient is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube? Prime the tubing with 20 mL of normal saline. Keep the vent lumen above the patient's stomach level. Maintain the patient in a high Fowler's position. Have the patient pin the tube to the thigh.

Keep the vent lumen above the patient's stomach level. The blue vent lumen should be kept above the patient's stomach to prevent reflux of gastric contents through it; otherwise it acts as a siphon. A one-way antireflux valve seated in the blue pigtail can prevent the reflux of gastric contents out the vent lumen. To prevent reflux, you do not prime the tubing, maintain the patient in a high Fowler's position, or have the patient pin the tube to the thigh.

The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly? Maintain intermittent or continuous suction at a rate greater than 120 mm Hg. Keep the vent lumen above the patient's waist to prevent gastric content reflux. Irrigate only through the vent lumen. Tape the tube to the head of the bed to avoid dislodgement.

Keep the vent lumen above the patient's waist to prevent gastric content reflux. The blue vent lumen should be kept above the patient's waist to prevent reflux of gastric contents through it; otherwise, it acts as a siphon.

A client is receiving continuous tube feedings at 75 mL/h. When the nurse checked the residual volume 4 hours ago, it was 250 mL, and now the residual volume is 325 mL. What is the priority action by the nurse? Discard the residual volume. Stop the continuous feeding. Decrease the rate to 40 mL/h. Notify the healthcare provider.

Notify the healthcare provider. The second residual volume is greater than the first. When excessive residual volume (more than 200 mL) of a nasogastric feeding occurs twice, the nurse notifies the healthcare provider. The nurse does not discard the aspirate because the client has partially digested this fluid. After discussing with the healthcare provider, the nurse may stop the continuous feeding for some time or decrease the rate of infusion, but stopping the tube feeding is not an independent nursing action.

A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse? Reinsert the nasogastric tube to the stomach. Notify the surgeon about the tube's removal. Place the nasogastric tube to the level of the esophagus. Document the discontinuation of the nasogastric tube.

Notify the surgeon about the tube's removal. If the nasogastric tube is removed accidently in a client who has undergone esophageal or gastric surgery, it is usually replaced by the health care provider. Care is taken to avoid trauma to the suture line. The nurse will not insert the tube to the esophagus or to the stomach in this situation. The nurse needs to do more than just document its removal. The nurse needs to notify the health care provider who will make a determination of leaving out or inserting a new nasogastric tube.

A nurse suspects that a client is developing rebound hypoglycemia secondary to parenteral nutrition being discontinued too rapidly. Which assessment support the nurse's suspicion? Select all that apply. Shakiness Reports of feeling flushed Tachycardia Dry, hot skin Weakness Confusion

Shakiness Tachycardia Weakness Confusion Signs and symptoms of rebound hypoglycemia include weakness, faintness, sweating, shakiness, feeling cold, confusion, and increased heart rate. The client with hypoglycemia will not report feeling flushed or having hot, dry skin.

Rebound hypoglycemia is a complication of parenteral nutrition caused by: glucose intolerance. fluid infusing rapidly. feedings stopped too abruptly. a cap missing from the port.

feedings stopped too abruptly. Rebound hypoglycemia occurs when the feedings are stopped too abruptly. Hyperglycemia is caused by glucose intolerance. Fluid overload is caused by fluids infusing too rapidly. An air embolism can occur from a cap missing on a port.

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for? -diaphoresis, vomiting, and diarrhea. -manifestations of electrolyte disturbances. -manifestations of hypoglycemia. -constipation, dehydration, and hypercapnia.

diaphoresis, vomiting, and diarrhea. The nurse must monitor for diaphoresis, vomiting, and diarrhea because these signs suggest an intolerance to the ordered enteral feeding solution. Other signs and symptoms of feeding intolerance include abdominal cramps, nausea, aspiration, and glycosuria. Electrolyte disturbances, constipation, dehydration, and hypercapnia are complications of enteral feedings, not signs of intolerance. Hyperglycemia, not hypoglycemia, is a potential complication of enteral feedings.

The client is receiving 50% dextrose parenteral nutrition with fat emulsion therapy through a peripherally inserted central catheter (PICC). The nurse has developed a care plan for the nursing diagnosis "Risk for infection related to contamination of the central catheter site or infusion line." The nurse includes the intervention: Change the transparent dressing every 3 days. Wear a face mask during dressing changes. Assess the PICC insertion site daily. Use clean gloves when providing site care.

Wear a face mask during dressing changes. The Centers for Disease Control and Prevention (CDC) recommends changing central vascular access device dressings every 7 days. During dressing changes, the nurse and client wear face masks to reduce the possibility of airborne contamination. The transparent dressing allows for frequent assessments of the site. This is to be done more frequently than daily. During dressing changes, the nurse wears sterile gloves.

A client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement (select all options that apply): Compares exposed tube length with original measurement Visually assesses the color of the aspirate Checks the pH of the gastric contents Confirms the tip of the tube with radiology Inserts 30 mL of tap water through the nasogastric tube

Compares exposed tube length with original measurement Visually assesses the color of the aspirate Checks the pH of the gastric contents The nasogastric tube must be checked every shift for placement when a client is receiving continuous feedings. Recommended methods are comparing the exposed nasogastric tube length to the original measurement, visually assessing the color of the aspirate, and checking the pH of the gastric contents with a pH sensor. Confirming tube placement with radiology is costly and may be performed at the time of initial insertion. Inserting tap water through the nasogastric tube does not verify placement.

The client is receiving a 25% dextrose solution of parenteral nutrition. The infusion machine is beeping, and the nurse determines the intravenous (IV) bag is empty. The nurse finds there is no available bag to administer. What is the priority action by the nurse? Request a new bag from the pharmacy department. Infuse a solution containing 10% dextrose and water. Flush the line with 10 mL of sterile saline. Catch up with the next bag when it arrives.

Infuse a solution containing 10% dextrose and water. If the parenteral nutrition solution runs out, a solution of 10% dextrose and water is infused to prevent hypoglycemia. The nurse would then order the next parenteral nutrition bag from the pharmacy. Flushing a peripherally inserted catheter is usually prescribed every 8 hours or per hospital established protocols. It is not the most important activity at this moment. The infusion rate should not be increased to compensate for fluids that were not infused, because hyperglycemia and hyperosmolar diuresis could occur.

A positive nitrogen balance indicates which condition? Tissue growth Starvation Burn injury Fever

Tissue growth A positive nitrogen balance exists when nitrogen intake exceeds nitrogen output and indicates tissue growth. A negative nitrogen balance exists with fever, starvation, and burn injury.

The most significant complication related to continuous tube feedings is: -the interruption of GI integrity. -a disturbance of intestinal and hepatic metabolism. -the increased potential for aspiration. -an interruption in fat metabolism and lipoprotein synthesis.

the increased potential for aspiration. Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the client receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis.

A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate? "It is a vent that prevents backflow of the secretions." "It acts as a siphon, pulling secretions into the clear tubing." "It helps regulate the pressure on the suction machine." "It works as a marker to make sure that the tube stays in place."

"It is a vent that prevents backflow of the secretions." The blue part of the Salem sump tube vents the larger suction-drainage tube to the atmosphere and, when kept above the patient's waist, prevents reflux of gastric contents through it. Otherwise it acts as a siphon. A gauge on the suction device regulates the pressure of the device. The tube has markings on it to aid in measurement.

A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube. -Apply gloves to the nurse's hands. -Measure the length of the tube that will be inserted. -Tilt the client's nose upward. -Sit the client in an upright position. -Instruct the client to lower the head and swallow. -Apply water-soluble lubricant to the tip of the tube.

-Sit the client in an upright position -Apply gloves to the nurse's hands -Measure the length of the tube that will be inserted -Apply water-soluble lubricant to the tip of the tube -Tilt the client's nose upward -Instruct the client to lower the head and swallow

The nurse is inserting a nasogastric tube for a patient with pancreatitis. What intervention can the nurse provide to allow facilitation of the tube insertion? Spray the oropharynx with an anesthetic spray. Have the patient maintain a backward tilt head position. Allow the patient to sip water as the tube is being inserted. Have the patient eat a cracker as the tube is being inserted.

Allow the patient to sip water as the tube is being inserted. During insertion, the patient usually sits upright with a towel or other protective barrier spread in a biblike fashion over the chest. The nostril may be swabbed or the oropharynx sprayed with an anesthetic agent to numb the nasal passage and suppress the gag reflex. The tip of the patient's nose is tilted upward, and the tube is aligned to enter the nostril. When the tube reaches the nasopharynx, the patient is instructed to lower the head slightly and, if able, to begin to swallow as the tube is advanced. The patient may also be encouraged to sip water through a straw to facilitate advancement of the tube if this action is not contraindicated.

A client with a feeding tube is to receive medication. The medication supplied is an enteric-coated tablet. Which of the following would be most appropriate? Check with the pharmacist to see of a liquid form is available. Dissolve the tablet in water after crushing it. Sprinkle the contents of the opened tablet into the tube. Give the tablet as is in its original state.

Check with the pharmacist to see of a liquid form is available. Enteric-coated tablets due to their formulation cannot be crushed. Rather the nurse would need to contact the pharmacist to see if there is a liquid form available. Some time-released tablet forms can be opened but cannot be crushed because doing so may release too much of the drug too quickly Giving the tablet as is in its original form would be inappropriate because it would not pass through the tube, thus not reaching its intended site for absorption.

A nurse is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply. Hypertension Diarrhea Decreased bowel sounds Tachycardia Diaphoresis

Diarrhea Tachycardia Diaphoresis Dumping syndrome is manifested by hypotension, diarrhea, tachycardia, and diaphoresis. The client often reports a feeling of fullness, nausea, and vomiting. Because of the rapid movement of water to the stomach and intestines, bowel sounds would most likely be increased.

The physician ordered a nasoenteric feeding tube with a tungsten-weighted tip. The nurse knows to obtain what kind of tube?

Dobbhoff A Dobbhoff is a nasoenteric feeding tube with a tungsten-weighted tip. Levin, Salem, and Sengstaken-Blakemore tubes are nasogastric tubes, not nasoenteric tubes

When assessing whether a client is a candidate for home parenteral nutrition, what would be important to address? Select all that apply. Family support Telephone access Marital status Motivation for learning Health status

Family support Telephone access Motivation for learning Health status Ideal candidates for home parenteral nutrition are patients who have a reasonable life expectancy after return home, have a limited number of illnesses other than the one that has resulted in the need for parenteral nutrition, and are highly motivated and fairly self-sufficient. Additional areas to consider include the client's ability to learn, availability of family interest and support, adequate finances, and the physical plan of the home including access to water, electricity, refrigeration, and telephone. The client's marital status is not important.

Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the: Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. Digestive process occurs more rapidly as a result of the feedings not having to pass through the esophagus. Feedings can be administered with the patient in the recumbent position. The patient cannot experience the deprivational stress of not swallowing.

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact. Regurgitation and aspiration are less likely to occur with a gastrostomy than with NG feedings.

A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate? Slow the current infusion rate so that it will last until the new solution arrives. Hang a solution of dextrose 10% and water until the new solution is available. Have someone go to the pharmacy to obtain the new solution. Begin an infusion of normal saline in another site to maintain hydration.

Hang a solution of dextrose 10% and water until the new solution is available. The infusion rate of the solution should not be increased or decreased; if the solution is to run out, a solution of 10% dextrose and water is used until the next solution is available. Having someone go to the pharmacy would be appropriate, but there is no way to determine if the person will arrive back before the solution runs out. Starting another infusion would be inappropriate. Additionally, the infusion needs to be maintained through the central venous access device to maintain patency.

The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also reports unpleasant tastes and odors. Which measure should be included in the client's plan of care? Ensure adequate hydration with additional water. Provide frequent mouth care. Keep the feeding formula refrigerated. Flush the tube with water before adding the feedings.

Provide frequent mouth care. Frequent mouth care helps to relieve the discomfort from dryness and unpleasant odors and tastes. It can be done with the help of ice chips and analgesic throat lozenges, gargles, or sprays. Adequate hydration is essential. If urine output is less than less than 500 mL/day, formula and additional water can be given as ordered. Keeping the feeding formula refrigerated and unopened until it is ready for use and flushing the tube with water before adding feedings are measures to protect the client from infections.

The dumping syndrome occurs when high-carbohydrate foods are administered over a period of less than 20 minutes. A nursing measure to prevent or minimize the dumping syndrome is to administer feedings:

With the patient in semi-Fowler's position to decrease transit time influenced by gravity. To avoid the dumping syndrome, the nurse should also give the feeding at room temperature, by continuous (not bolus) insertion. Dilution of the feeding is not necessary

The primary source of microorganisms for catheter-related infections are the skin and the: catheter tubing. catheter hub. IV fluid bag. IV tubing.

catheter hub. The primary sources of microorganisms for catheter-related infections are the skin and the catheter hub. The catheter site is covered with an occlusive gauze dressing that is usually changed every other day.

The nurse cares for a client who receives parenteral nutrition (PN). The nurse notes on the care plan that the catheter will need to be removed 6 weeks after insertion and that the client's venous access device is a: nontunneled central catheter. peripherally inserted central catheter . tunneled central catheter. implanted port.

nontunneled central catheter. Nontunneled central catheters are used for short-term (less than 6 weeks) IV therapy in acute care settings. The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored; it allows the client freedom of movement and provides easy access to the dressing site. Peripherally inserted central catheter (PICC) lines may be used for intermediate terms (3 to 12 months). Tunneled central catheters are for long-term use and may remain in place for many years. Implanted ports are devices also used for long-term home IV therapy (e.g., Port-A-Cath, Mediport, Hickman Port, P.A.S. Port).

The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every shift. hour. 12 hours. 24 hours.

shift. Each nurse caring for the client is responsible for verifying that the tube is located in the proper area for continuous feeding. Checking for placement each hour is unnecessary unless the client is extremely restless or there is basis for rechecking the tube due to other client activities. Checking for placement every 12 or 24 hours does not meet the standard of care for the client receiving continuous tube feedings.

Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding? 30 minutes 1 hour 90 minutes 2 hours

1 hour The semi-Fowler position is necessary for a nasogastric (NG) feeding, with the client's head elevated at least 30 to 45 degrees to reduce the risk for reflux and pulmonary aspiration. This position is maintained for at least 1 hour after completion of an intermittent tube feeding and is maintained at all times for clients receiving continuous tube feedings.

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

260 Intake includes all the components listed in the intake column, which amounts to 710 mL. The output, which is the urine of 450 mL, is subtracted from the total intake. This leaves 260 mL as a positive fluid balance.

A patient has a gastric sump tube attached to low intermittent suction. The nurse empties the suction collection chamber and records an output of 320 mL for this 8-hour shift. The record shows that the tube had been irrigated with 20 mL of normal saline twice this shift. What would be the actual output of the gastric sump tube?

280

A patient has a gastric sump tube attached to low intermittent suction. The nurse empties the suction collection chamber and records an output of 320 mL for this 8-hour shift. The record shows that the tube had been irrigated with 20 mL of normal saline twice this shift. What would be the actual output of the gastric sump tube?

280 The output measured includes the two 20 mL irrigations. To determine the actual output, the nurse would subtract the amount of irrigation used (in this case 40 mL total) from the total output (in this case 320 mL) and arrive at an output of 280 mL.

The nurse administers a tube feeding to a client via the intermittent gravity drip method. The nurse should administer the feeding over at least which period of time? 15 minutes 30 minutes 60 minutes 80 minutes

30 minutes Tube feedings administered via intermittent gravity drip should be administered over 30 minutes or longer.

A client newly diagnosed with acute lymphocytic leukemia has a right subclavian central venous catheter in place. The nurse who's caring for the client is teaching a graduate nurse about central venous catheter care. The nurse should instruct the graduate nurse to change the central venous catheter dressing every:

48 hours

A patient is receiving a continuous tube feeding. The nurse notes that the feeding tube was last irrigated at 2 p.m. The nurse would plan to irrigate the tube again at which time? 4 p.m. to 6 p.m. 6 p.m. to 8 p.m. 8 p.m. to 10 p.m. 10 p.m. to 12 a.m.

6 p.m. to 8 p.m. The recommendation is to irrigate the feeding tube of patients receiving continuous tube feedings every 4 to 6 hours. For this patient, the nurse would irrigate the tube next at 6 p.m. to 8 p.m.

A client is receiving a parenteral nutrition admixture that contains carbohydrates, electrolytes, vitamins, trace minerals, and sterile water and is now scheduled to receive an intravenous fat emulsion (Intralipid). What is the best action by the nurse? Stops the admixture while the fat emulsion infuses Starts a peripheral IV site to administer the fat emulsion Attaches the fat emulsion tubing to a Y connector close to the infusion site Connects the tubing for the fat emulsion above the 1.5 micron filter

Attaches the fat emulsion tubing to a Y connector close to the infusion site An intravenous fat emulsion is attached to a Y connector close to the infusion site. The fat emulsion is administered simultaneously with the parenteral nutrition admixture. A separate peripheral IV site is not necessary. The fat emulsion is not administered through a filter.

A client had a central line inserted for parenteral nutrition and is awaiting transport to the radiology department for catheter placement verification. The client reports feeling anxious and has a respiratory rate of 28 breaths/minute. What is the next action of the nurse? Auscultate lung sounds Position client flat in bed Apply nasal cannula oxygen Consult with the healthcare provider

Auscultate lung sounds Following placement of a central line, the client is at risk for a pneumothorax. The client's report of anxiety and increased respiratory rate may be the first signs and symptoms of a pneumothorax. The nurse should first assess the client by auscultating lung sounds before applying oxygen, placing the client in Fowler's position, and consulting with the healthcare provider about findings.

The nurse is to administer a cyclic feeding through a gastric tube. It is most important for the nurse to: Check the residual volume before the feeding. Accurately assess the amount of fluid infused. Elevate the head of the bed to 45 degrees. Change the tube feeding container and tubing.

Elevate the head of the bed to 45 degrees. All the options are things that the nurse will do when administering a cyclic tube feeding. Elevating the head of the bed to 30 to 45 degrees assists in preventing aspiration into the lungs. This is a priority according to Maslow's hierarchy of needs.

The nurse assesses a patient who recently had a nasoenteric intubation. Symptoms of oliguria, lethargy, and tachycardia in the patient would indicate to the nurse what common complication?

Fluid volume deficit

The nurse assesses a patient who recently had a nasoenteric intubation. Symptoms of oliguria, lethargy, and tachycardia in the patient would indicate to the nurse what common complication? A cardiac dysrhythmia Fluid volume deficit Mucous membrane irritation Pulmonary complications

Fluid volume deficit Symptoms of fluid volume deficit include dry skin and mucous membranes, decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate.

The health care provider orders the insertion of a single lumen nasogastric tube. When gathering the equipment for the insertion, what will the nurse select? Salem sump tube Miller-Abbott tube Sengstaken-Blakemore tube Levin tube

Levin tube A Levin tube is a single lumen nasogastric tube. A Salem sump tube is a double lumen nasogastric tube; a Sengstaken-Blakemore tube is a triple lumen nasogastric tube. A Miller-Abbott tube is a double lumen nasoenteric tube.

A client receiving tube feedings has prescriptions for several drugs. Which drugs would the nurse expect to administer to the client without any special preparation? Select all that apply. Liquid stool softener Sublingual nitroglycerin Enteric-coated aspirin Sustained-release antihypertensive Acetaminophen tablet

Liquid stool softener Sublingual nitroglycerin Liquid medications do not require any special preparation for administration via a feeding tube. Buccal or sublingual tablets are administered as prescribed. They are absorbed through the mucosa of the cheek or under the tongue and thus would not be administered through the feeding tube. Enteric-coated aspirin and sustained-release antihypertensive could not be given as is through a feeding tube. A change in formulation would be needed. An acetaminophen tablet would need to be crushed and dissolved in water before being given.

The nurse is inserting a nasoenteric tube for a patient with a paralytic ileus. How long does the nurse anticipate the tube will be required? (Select all that apply.) Until bowel sound is present Until flatus is passed Until peristalsis is resumed Until the patient stops vomiting Until the tube comes out on its own

Until bowel sound is present Until flatus is passed Until peristalsis is resumed Before removing an enteral tube, the nurse may intermittently clamp it for a trial period of several hours to ensure that the patient does not experience nausea, vomiting, or distention. Before any tube is removed, it is flushed with 10 mL of water or normal saline to ensure that it is free of debris and away from the gastric lining. Gloves are worn when removing the tube. The tube is withdrawn gently and slowly for 15 to 20 cm (6 to 8 in) until the tip reaches the esophagus; the remainder is withdrawn rapidly from the nostril. If the tube does not come out easily, force should not be used, and the problem should be reported to the primary provider. As the tube is withdrawn, it is concealed in a towel to prevent secretions from soiling the patient or nurse. After the tube is removed, the nurse provides oral hygiene.

To ensure patency of central venous line ports, diluted heparin flushes are used: -with continuous infusions. -before drawing blood. -when the line is discontinued. -daily when not in use.

daily when not in use. Daily instillation of dilute heparin flush when a port is not in use will maintain the port. Continuous infusion maintains the patency of each port. Heparin flushes are used after each intermittent infusion. Heparin flushes are used after blood drawing to prevent clotting of blood within the port. Heparin flush of ports is not necessary if a line is to be discontinued.

The nurse attempts to unclog a client's feeding tube. Attempts with warm water agitation and milking the tube are unsuccessful. The nurse uses evidence-based practice principles when subsequently using which technique to unclog the tube? digestive enzymes and sodium bicarbonate cola mixed with cranberry juice sodium bicarbonate mixed with water meat tenderizer diluted with saline

digestive enzymes and sodium bicarbonate The nurse should attempt to unclog the tube with digestive enzymes activated with sodium bicarbonate. Although historically both cranberry juice and cola have sometimes been used to unclog feeding tubes, evidence has shown that their acidic nature worsens the clog by causing precipitation of proteins. Meat tenderize diluted with saline is not applicable.

The nurse prepares to administer all of a client's medications via feeding tube. The nurse consults the pharmacist and/or physician when the nurse notes which type of oral medication on the client's medication administration record? simple compressed tablets buccal or sublingual tablets enteric-coated tablets soft, gelatin capsules filled with liquid

enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change in the form of medication is necessary for clients with tube feedings. Simple compressed tablets may be crushed and dissolved in water for clients receiving oral medications by feeding tube. Buccal or sublingual tablets are absorbed by mucous membranes and may be given as intended to the client undergoing tube feedings. The nurse may make an opening in the capsule and squeeze out contents for administration by feeding tube.

The nurse cares for a client who receives continuous parenteral nutrition (PN) through a Hickman catheter and notices that the client's solution has run out. No PN solution is currently available from the pharmacy. What should the nurse do? stop the infusion and flush the line hang normal saline with potassium hang 10% dextrose and water hang 5% dextrose and water

hang 10% dextrose and water If the parenteral nutrition (PN) solution runs out and no PN is available, the nurse should hang 10% dextrose and water until the PN becomes available.

Hickman and Groshong are examples of which type of central venous access device? implanted ports tunneled central catheters peripherally inserted central catheters nontunneled central catheters

tunneled central catheters Hickman and Groshong catheters are examples of tunneled central catheters. MediPort is an implanted port. A percutaneous subclavian Arrow is an example of a nontunneled central catheter. A peripherally inserted central catheter (PICC) line is used for intermediate-term IV therapy for the hospital, long-term care, or the home setting.

A nurse is preparing to perform a dressing change to the site of a patient's central venous catheter used for parenteral nutrition. Which equipment and supplies would the nurse need to gather? Select all that apply.

• Masks • Skin antiseptic • Alcohol wipes • Sterile gauze pads

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

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