KLZ Invasive GI Unit

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

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

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

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?

"I can crush and mix my medication with my formula."

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?

"I will cover the catheter so he cannot see it."

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? 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

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? 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

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 bed

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

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

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."

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

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

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?

Swollen, bleeding gums

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

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

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

A nurse is caring for a client who is receiving total paenteral 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

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 based on understanding of which of the following? A. Laxatives are contraindicated in client who have a small bowel obstructions B. Bulk-forming laxatives such as psyllium should be substituted for the 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 client who have a small bowel obstructions

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

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

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

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

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

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

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

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? 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

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

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

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."

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 appetities 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

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."

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

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 tub

C. Check to see if the suction equipment is working

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

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

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

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

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

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