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

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 works as a marker to make sure that the tube stays in place." "It is a vent that prevents backflow of the secretions." "It helps regulate the pressure on the suction machine." "It acts as a siphon, pulling secretions into the clear tubing."

"It is a vent that prevents backflow of the secretions." Explanation: 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 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. Explanation: 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.

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 Explanation: 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 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? 8 p.m. to 10 p.m. 4 p.m. to 6 p.m. 6 p.m. to 8 p.m. 10 p.m. to 12 a.m.

6 p.m. to 8 p.m. Explanation: 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 Explanation: 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.

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

pneumothorax Explanation: 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 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? Flushing the feeding tube. Lowering the head of the bed. Monitoring the feeding closely. Increasing the feeding rate.

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

catheter hub. Explanation: 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.

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. Explanation: 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 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 soft, gelatin capsules filled with liquid buccal or sublingual tablets enteric-coated tablets

enteric-coated tablets Explanation: 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.

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

feedings stopped too abruptly. Explanation: 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.

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 decreased pulse rate. elevated blood pressure. loose, watery stools. increased urination.

loose, watery stools. Explanation: 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.

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. Explanation: 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 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? 10-mL 5-mL 20-mL 30-mL

30-mL Explanation: 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 g Explanation: 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 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? Keep the vent lumen above the patient's stomach level. Maintain the patient in a high Fowler's position. Prime the tubing with 20 mL of normal saline. Have the patient pin the tube to the thigh.

Keep the vent lumen above the patient's stomach level. Explanation: 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 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 the tube comes out on its own Until peristalsis is resumed Until the patient stops vomiting Until flatus is passed

Until bowel sound is present Until flatus is passed Until peristalsis is resumed Explanation: 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.

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. Explanation: 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 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. 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.

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

1 hour Explanation: 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 nurse is caring for a patient who has dumping syndrome from high carbohydrate foods being administered over a period of less than 20 minutes. What is a nursing measure to prevent or minimize the dumping syndrome? Administer the feeding with the patient in semi-Fowler's position to decrease transit time influenced by gravity. Administer the feeding with about 100 mL of fluid to dilute the high carbohydrate concentration. Administer the feeding by bolus to prevent continuous intestinal distention. Administer the feeding at a warm temperature to decrease peristalsis.

Administer the feeding with the patient in semi-Fowler's position to decrease transit time influenced by gravity. Explanation: The following strategies may help prevent some of the uncomfortable signs and symptoms of dumping syndrome related to tube feeding: Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. Administer feedings at room temperature, because temperature extremes stimulate peristalsis. Administer feeding by continuous drip (if tolerated) rather than by bolus, to prevent sudden distention of the intestine. Advise the patient to remain in semi-Fowler's position for 1 hour after the feeding; this position prolongs intestinal transit time by decreasing the effect of gravity. Instill the minimal amount of water needed to flush the tubing before and after a feeding, because fluid given with a feeding increases intestinal transit time.

The nurse is inserting a nasogastric tube for a patient with pancreatitis. What intervention can the nurse provide to allow facilitation of the tube insertion? 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. Explanation: 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 nurse is caring for a client receiving parenteral nutrition at home. The client was discharged from the acute care facility 4 days ago. What would the nurse include in the client's plan of care? Select all that apply. Strict bedrest Intake and output monitoring Daily weights Daily transparent dressing changes Calorie counts for oral nutrients

Daily weights Intake and output monitoring Calorie counts for oral nutrients Explanation: For the client receiving parenteral nutrition at home, the nurse would obtain daily weights initially, decreasing them to two to three times per week once the client is stable. Intake and output monitoring also is necessary to evaluate fluid status. Calorie counts of oral nutrients are used to provide additional information about the client's nutritional status. Transparent dressings are changed weekly. Activity is encouraged based on the client's ability to maintain muscle tone. Strict bedrest is not appropriate.

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? Diarrhea Dry skin Hyperglycemia Slowed heart beat

Diarrhea Explanation: 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.

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. Explanation: 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.

A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. What actions are a priority for the nurse to perform prior to administration? Select all that apply. Place a 1.5-micron filter on the tubing Assess for patency of the peripheral intravenous site Ensure availability of an infusion pump Administer the intravenous antibiotic in the same tubing as the parenteral nutrition Ensure completion of baseline monitoring of the complete blood count (CBC) and chemistry panel

Ensure availability of an infusion pump Ensure completion of baseline monitoring of the complete blood count (CBC) and chemistry panel Place a 1.5-micron filter on the tubing Explanation: Parenteral nutrition with dextrose concentrations of greater than 10% should not be administered through peripheral veins. An infusion pump should always be used for the administration of parenteral nutrition. Standing orders are initiated that include monitoring of CBC and chemistry panel prior to the start of parenteral nutrition. Medications should not be administered in the same IV line as the parenteral nutrition because of potential incompatibilities with the components of the nutritional solution. A special filter (1.5-micron filter) is used with parenteral nutrition.

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 Pulmonary complications Mucous membrane irritation A cardiac dysrhythmia

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

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

Flush with 10 mL of water. Explanation: 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.

Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the: Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. The patient cannot experience the deprivational stress of not swallowing. 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.

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. Explanation: 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. Explanation: 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 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? 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. Request a new bag from the pharmacy department.

Infuse a solution containing 10% dextrose and water. Explanation: 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.

he 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? Irrigate only through the vent lumen. Tape the tube to the head of the bed to avoid dislodgement. 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.

Keep the vent lumen above the patient's waist to prevent gastric content reflux. Explanation: 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 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 Little food in the working refrigerator Water of low pressure that can be obtained through all faucets Electricity that loses power, usually for short duration, during storms

No land line; cell phone available and taken by family member during working hours Explanation: 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.

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. Document the discontinuation of the nasogastric tube. Notify the surgeon about the tube's removal. Place the nasogastric tube to the level of the esophagus.

Notify the surgeon about the tube's removal. Explanation: 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 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 Evaluate for masses in the large colon Diagnose gastrointestinal motility disorders Administer nutritional substances Flush ingested toxins from the stomach

Remove gas and fluids from the stomach Diagnose gastrointestinal motility disorders Flush ingested toxins from the stomach Administer nutritional substances Explanation: Gastrointestinal intubation is used to decompress the stomach and remove gas and fluids, lavage the stomach and remove ingested toxins or other harmful materials, diagnose disorders of GI motility, administer medications and feedings, compress a bleeding site, and aspirate gastric contents for analysis. Because gastrointestinal intubation involves the insertion of a tube into the stomach, beyond the pylorus into the duodenum or jejunum, it could not be used to evaluate for masses in the large colon.

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

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

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 Explanation: 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.

A client receives tube feedings after an oral surgery. The nurse manages tube feedings to minimize the risk of aspiration. Which measure should the nurse include in the care plan to reduce the risk of aspiration? Avoid cessation of feedings and adjust patient head of bed. Administer 15 to 30 mL of water before and after medications and feedings. Use semi-Fowler position during, and 60 minutes after, an intermittent feeding. Change the tube feeding container , tubing , and adjust patient head of bed.

Use semi-Fowler position during, and 60 minutes after, an intermittent feeding. Explanation: To minimize the risk of aspiration, it is important to place the client in a semi-Fowler position during, and 60 minutes after, an intermittent feeding because proper positioning prevents regurgitation. Checking tube placement and gastric residual prior to feedings is another important measure because it prevents improper infusion and vomiting. If aspiration is suspected, feeding should be stopped as cessation prevents further problems and allows for treatment of the immediate problem. Changing tube feeding container and tubing, monitoring weight daily, and administering 15 to 30 mL of water before and after medications and feedings are measures to maintain tube function.

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 . implanted port. tunneled central catheter.

nontunneled central catheter. Explanation: 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 Explanation: 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.