PREPU CH 39 MANAGEMENT IF PTS WITH ORAL AND ESOPHAGEAL DOS

The nurse is caring for a client receiving continuous tube feedings. The nurse knows that flushing the tube to maintain patency will be done at certain times. Which of the following times would the nurse check for patency? Select all that apply.

- Before and after medication administration - When the feeding is interrupted for any reason - Every 4 hours - After checking for gastric residual Maintaining feeding tube function is a responsibility of the nurse. To ensure patency and to decrease the chance of bacterial growth, sludge build-up, or occlusion of the tube, at least 30 mL of water flush is recommended for adults receiving tube feedings every 4 hours, after checking for gastric residual, before and after medication administration, and when the feeding is interrupted for any reason. The tube does not need to be flushed when refilling the formula container.

A client with a nasogastric tube set to low intermittent suction is receiving D51/2NS at 100 mL/hr. The nurse has identified a nursing diagnosis of deficient fluid volume. Which of the following are data that support this diagnosis? Select all that apply.

- Fluid output of 2150 mL and total fluid intake of 2000 mL for the past 24 hours - Urine output that decreased from 60 to 40 mL/hr - Heart rate that increased from 82 to 98 beats/min within 2 hours Data supporting a nursing diagnosis of deficient fluid volume include dry skin and mucus membranes, decreased urinary output, lethargy, and increased heart rate.

A nurse is completing an assessment on a client with a postoperative neck dissection. The nurse notices excessive bleeding from the dressing site and suspects possible carotid artery rupture. What action should the nurse take first?

Apply pressure to the bleeding site Explanation: The first action for the nurse is to apply pressure to the bleeding site. The nurse will need to obtain assistance, elevate the head of the bed, and notify the surgeon, but client care is most important initially.

Which tube is a nasoenteric feeding tube?

Dobbhoff

A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client?

Dumping syndrome Explanation: Osmolality is an important consideration for clients receiving tube feedings through the duodenum or jejunum because feeding formulas with a high osmolality may lead to undesirable effects. When a concentrated solution of high osmolality entering the stomach is taken in quickly or in large amounts, the small intestines expand and water moves rapidly into the intestinal lumen from fluid surrounding the organs and the vascular compartment. The client may have feelings of fullness, nausea, cramping, dizziness, diaphoresis, and osmotic diarrhea, which indicates dumping syndrome. The client's symptoms are not caused by a diverticulosis, paralytic ileus, or a small bowel obstruction.

The following appears on the medical record of a male patient receiving parenteral nutrition:WBC: 6500/cu mmPotassium 4.3 mEq/LMagnesium 2.0 mg/dLCalcium 8.8 mg/dLGlucose 190 mg/dL Which finding would alert the nurse to a problem?

Glucose level Explanation: Of the values listed, only the glucose level is above normal, indicating hyperglycemia, a potential complication of parenteral nutrition.

A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?

The client lying in a lateral position, with the head of bed flat Explanation: A client who has had neck surgery is at risk for neck swelling. To prevent respiratory complications, the head of the bed should be at least at a 30-degree angle. This position gives the lungs room to expand and decreases swelling by promoting venous and lymphatic drainage. This position also minimizes the risk of aspiration. Serosanguineous drainage on the dressing, a Foley bag containing amber urine, and levofloxacin infusing aren't causes for concern.

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. Explanation: 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 most common symptom of esophageal disease is

dysphagia