303 Hinkle PrepU Chapter 44: Digestive and Gastrointestinal Treatment Modalities

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 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?

6 pm to 8 pm 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.

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?

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.

The primary source of microorganisms for catheter-related infections are the skin and the

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 nurse providing care to a patient who is receiving nasogastric tube feedings finds that the tube is clogged. Which of the following is no longer considered appropriate to use to unclog the tube?

cranberry juice To unclog a feeding tube, air insufflation, digestive enzymes mixed with warm water, or a commercial enzyme product could be used. Cola and cranberry juice are no longer advocated for use in clearing a clogged tube.

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?

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.

The nurse monitors a client with nasoenteric intubation. When should the nurse contact the physician?

urinary output 20mL/hour The nurse should notify the physician when the client has a urinary output of 20 mL/hr as this is a decreased urinary rate. Decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate are signs and symptoms of fluid volume deficit. A heart rate of 100, blood pressure of 118/72, and moist mucous membranes are findings that are within acceptable ranges/limits and do not indicate a fluid volume deficit.

The nurse checks residual content before each intermittent tube feeding. When should the patient be reassessed?

when the residual is greater than 200mL Although a residual volume of 200 mL or greater is generally considered a cause for concern in patients at high risk for aspiration, feedings do not necessarily need to be withheld in all patients.

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 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.

Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding?

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.

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.

Daily weights Intake and output monitoring Calorie counts for oral nutrients 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 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 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 client cannot tolerate oral feedings due to an intestinal obstruction and is NPO. A central line has been inserted, and the client is being started on parenteral nutrition (PN). What actions would the nurse perform while the client receives PN? Select all that apply.

Weigh the client every day. Check blood glucose level every 6 hours. Document intake and output When a client is receiving PN through a central line, the nurse weighs the client daily, checks blood glucose level every 6 hours, and documents intake and output. These actions are to ensure the client is receiving optimal nutrition. The nurse also performs activities to prevent infection, such as covering the insertion site with a transparent dressing that is changed weekly and/or prn and using sterile technique during catheter site dressing changes.

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 the IV through the catheter The nurse should clean the port with an alcohol pad before administering I.V. fluid through the catheter to prevent microorganisms from entering the bloodstream. Using clean technique when accessing the port with a needle, cleaning the needle with a povidone-iodine solution, or reusing a needle would break sterile technique.

To ensure patency of central venous line ports, diluted heparin flushes are used

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.

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, 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 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 enzyme 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.

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 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 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 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?

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.

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?

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.

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?

monitor 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.

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 fmaily members 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.

A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse?

notify the surgeon of the tubes 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.

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?

place the client in a semi fowlers 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.

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?

the distance measured from the tip of the nose 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.

Rebound hypoglycemia is a complication of parenteral nutrition caused by

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.

The nurse confirms placement of a client's nasogastric (NG) tube using a combination of visual and pH assessment of the aspirate. The nurse determines that the NG tube remains properly placed when the pH of the aspirate is

acidic The pH of gastric aspirate is acidic (1 to 5).

Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the:

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 client has a gastrointestinal tube that enters the stomach through a surgically created opening in the abdominal wall. The nurse documents this as which of the following?

gastronomy tube A gastrostomy tube enters the stomach through a surgically created opening into the abdominal wall. A jejunostomy tube enters jejunum or small intestine through a surgically created opening into the abdominal wall. A nasogastric tube passes through the nose into the stomach via the esophagus. An orogastric tube passes through the mouth into the stomach.

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 of the patient in semi fowlers to decrease transit time influenced by gravity 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 most significant complication related to continuous tube feedings is

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 client has been receiving intermittent tube feedings for several days at home. The nurse notes the findings as shown in the accompanying documentation. The nurse reports the following as an adverse reaction to the tube feeding:

fasting blood glucose level An adverse reaction to tube feedings is an elevated blood glucose level. The physical assessment data and renal function and liver function studies are normal.

A nurse is preparing to administer a 500 mL bolus tube feeding to a patient. The nurse anticipates administering this feeding over which time frame?

10-15 minutes Typically a bolus tube feeding of 300 to 500 mL requires about 10 to 15 minutes to complete.

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 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.

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 inserts a nasogastric tube into the right nares of a patient. When testing the tube aspirate for pH to confirm placement, what does the nurse anticipate the pH will be if placement is in the lungs?

6 Determining the pH of the tube aspirate is a more accurate method of confirming tube placement than is maintaining tube length or visually assessing tube aspirate. The pH method can also be used to monitor the advancement of the tube into the small intestine. The pH of gastric aspirate is acidic (1 to 5), typically less than 4. The pH of intestinal aspirate is approximately 6 or higher, and the pH of respiratory aspirate is more alkaline.

A client is recovering from percutaneous endoscopic gastrostomy (PEG) tube placement. The nurse

administers an initial bolus of 50 mL water The first fluid nourishment may consist of water, saline, or 10% dextrose. This may be administered as a bolus of 30 to 60 mL. By the second day, formula feeding may begin. A gauze dressing is applied between the tube insertion site and the gastrostomy tube. The dressing is changed daily or as needed. The nurse gently manipulates the stabilizing disk daily to prevent skin breakdown.

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?

allow the patient to sip water when 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 nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to

auscultate lung sounds every 4 hours Pulmonary complications may occur as a result of nasogastric intubation. It is a high priority according to Maslow's hierarchy of needs and takes a higher priority over assessing the nose, changing nasal tape, or applying a water-based lubricant.

The following appears on the medical record of a male patient receiving parenteral nutrition: WBC: 6500/cu mm Potassium 4.3 mEq/L Magnesium 2.0 mg/dL Calcium 8.8 mg/dL Glucose 190 mg/dL Which finding would alert the nurse to a problem?

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

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 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.

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?

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 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?

keep the vent lumen above the patients waist to prevent gastric contents 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.

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?

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.

When a central venous catheter dressing becomes moist or loose, what should a nurse do first?

remove the dressing, clean the site, and apply a new dressing A nurse maintaining a central venous catheter should change the dressing every 72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the nurse should use sterile technique to clean around the site in accordance with facility policy. After the cleaning solution has dried, the nurse should cover the site with a transparent semipermeable dressing. A nurse who notes drainage on a wound dressing should draw a circle around the moist spot and note the date and time. She should notify the physician if she observes any catheter-related complications. Only a nurse with the appropriate qualifications may remove a central venous catheter, and a moist or loose dressing isn't a reason to remove the catheter.

The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every

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.

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 the catheter ports from the distal end to the insertion site Proper cleansing of a CVAD includes cleaning the insertion site with a chlorhexidine solution in a circular motion from insertion site outward. The nurse will obtain another pair of sterile gloves to perform the procedure if contamination of gloves occurs. The nurse cleanses from insertion site outward to distal catheter ports.