Adult Health Ch. 44

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."

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

1 hour

A patient has a gastric sump tube inserted and attached to low intermittent suction. The physician has ordered the tube to be irrigated with 30 mL of normal saline every 6 hours. When reviewing the patient's intake and output record for the past 24 hours, the nurse would expect to note that the patient received how much fluid with the irrigation?

120 mL

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

260 mL

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 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 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

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 as the tube is being inserted.

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.

Calorie counts for oral nutrients Daily weights Intake and output monitoring

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

Catheter hub

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.

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

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

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 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.

A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is

Inserted into the lungs

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.

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.

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

catheter hub.

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

continuous feedings

The nurse on an evidence-based practice council makes recommendations to ensure patency of nontunneled central venous lines. The nurse recommends that daily saline and diluted heparin flushes be used in which situation?

daily when not in use

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

daily when not in use.

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.

Rebound hypoglycemia is a complication of parenteral nutrition caused by

feedings stopped too abruptly.

Which condition is caused by improper catheter placement and inadvertent puncture of the pleura?

pneumothorax

The nurse teaches an unlicensed caregiver about bathing clients who are receiving tube feedings. The most significant complication related to continuous tube feedings is the

potential risk for aspiration.

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

shift

The most significant complication related to continuous tube feedings is

the increased potential for aspiration.

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

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration.

A nurse is providing home care to a client receiving intermittent tube feedings. The client wants to take an over-the-counter allergy medication. The medication would need to be given via feeding tube because the client has difficulty swallowing. The nurse checks the medication and finds that it is a timed-release tablet. Which action by the nurse would be most appropriate?

Check with the pharmacy for an alternative formulation for the drug.

Which finding would alert the nurse to a problem?

Glucose level

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.

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

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 to the earlobe and from the earlobe to the xiphoid process

The nurse is inserting a nasogastric tube and the patient begins coughing and is unable to speak. What does the nurse suspect has occurred?

The nurse has inadvertently inserted the tube into the trachea.

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 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.

After teaching nursing students about methods to assess gastric tube placement, the instructor determines that the teaching was successful when the group identifies which of the following as the most accurate method?

X-ray visualization

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

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

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

Notify the surgeon about the tube's removal.

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 is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply.

Tachycardia Diarrhea Diaphoresis

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

A positive nitrogen balance indicates which condition?

Tissue growth

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?

Infuse a solution containing 10% dextrose and water.

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 patient's waist to prevent gastric content reflux.

When assisting with the plan of care for a client receiving tube feedings, which of the following would the nurse include to reduce the client's risk for aspiration?

Keeping the client in a semi-Fowler's position at all times.

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?

30-mL

The nurse is caring for a patient who has dumping syndrome from high-carbohydrate foods being administered over a period of fewer 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 the effect of gravity on transit time.

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 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?

Attaches the fat emulsion tubing to a Y connector close to the infusion site

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.