Ch. 45 PrepU
The nurse administers a tube feeding to a client via the intermittent gravity drip method. The nurse should administer the feeding over at least which period of time?
30 minutes
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
A client is recovering from percutaneous endoscopic gastrostomy (PEG) tube placement. The nurse
Administers an initial bolus of 50 mL water
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 to 15 minutes
The nurse is to insert a postpyloric feeding tube. How can the nurse aid in placement of the tube past the pylorus?
Administer prescribed metoclopramide
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
While caring for a patient who has had radical neck surgery, the nurse notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What does the nurse know is an expected amount of drainage in the wound unit?
Approximately 80-120 mL
A client who underwent abdominal surgery and has a nasogastric (NG) tube in place begins to complain of abdominal pain that he describes as "feeling full and uncomfortable." Which assessment should the nurse perform first?
Assess patency of the NG 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 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
A nurse is preparing to assist a health care provider with a peripherally inserted central catheter. The nurse demonstrates understanding of this procedure by preparing which insertion site?
Basilic vein
The nurse is caring for a group of clients. Which client(s) would be a candidate for total parenteral nutrition (TPN)?
Child with short bowel syndrome Middle-aged man with acute pancreatitis Man with two-thirds of his colon removed
A client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement
Compares exposed tube length with original measurement Visually assesses the color of the aspirate Checks the pH of the gastric contents
The nurse collaborates with the physician and dietician to determine the best type of tube feeding for a client at risk for diarrhea due to hypertonic feeding solutions. Which type of feedings should the nurse suggest?
Continuous feedings
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?
Until bowel sound is present Until flatus is passed Until peristalsis is resumed
The nurse is caring for an older adult who reports xerostomia. The nurse evaluates for use of which medication?
Diuretics
Which tube is a nasoenteric feeding tube?
Dobbhoff
The nurse is to administer a cyclic feeding through a gastric tube. It is most important for the nurse to
Elevate the head of the bed to 45 degrees
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?
Ensure availability of an infusion pump Ensure completion of baseline monitoring of the CBC and chemistry panel Place a 1.5-micron filter on the tubing
An elderly client states, "I don't understand why I have so many caries in my teeth." What assessment made by the nurse places the client at risk for dental caries?
Exhibiting hemoglobin A1C 8.2
When assessing whether a client is a candidate for home parenteral nutrition, what would be important to address?
Family support Telephone access Motivation for learning Health status
A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition?
Gastroesophageal reflux disease
The nurse is caring for a comatose patient and administering gastrostomy feedings. What does the nurse understand is the reason that gastrostomy feedings are preferred to nasogastric (NG) feedings in the comatose patient?
Gastroesophageal sphincter is intact, lessening the possibility of regurgitation
A client with human immunodeficiency virus (HIV) comes to the clinic and is experiencing white patches on the lateral border of the tongue. What type of lesions does the nurse document?
Hairy leukoplakia
After teaching a client about the procedure for inserting a nontunneled central catheter, the nurse determines that the client has understood the instructions based on which statement?
I will be lying on my back but my legs will be higher than my head
A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess?
Increasing difficulty in swallowing
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?
Intake and output monitoring Daily weights Calorie counts for oral nutrients
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 receiving tube feedings has prescriptions for several drugs. Which drugs would the nurse expect to administer to the client without any special preparation?
Liquid stool softener Sublingual nitroglycerin
A nurse is providing education to a client with GERD. The client asks what measures can be taken independently to help reduce the symptoms. Which interventions would the nurse recommend?
Maintaining an upright position following meals Avoiding foods that intensify symptoms
A nurse is preparing to perform a dressing change to the site of a client's central venous catheter used for parenteral nutrition. Which equipment and supplies would the nurse need to gather?
Masks, skin antiseptic, alcohol wipes, sterile gauze pads
A client has been taking a 10-day course of antibiotics for pneumonia. The client has been having white patches that look like milk curds in the mouth. What treatment will the nurse educate the client about?
Nystatin
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-Fowler's position with the head of the bed at 45 degrees
The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. What is the nurse's priority action?
Place the client in the Fowler's position
A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure?
Remove gas and fluids from the stomach Diagnose gastrointestinal motility disorders Flush ingested toxins from the stomach Administer nutritional substances
A nurse suspects that a client is developing rebound hypoglycemia secondary to parenteral nutrition being discontinued too rapidly. Which assessment support the nurse's suspicion?
Shakiness, tachycardia, weakness, confusion
The nurse is caring for client scheduled to undergo radical neck dissection. During preoperative teaching, the nurse states that an associated complication is
Shoulder drop
A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube.
Sit the client in an upright position Apply gloves to hands Measure the length of the tube that will be inserted Apply water-soluble lubricant to the tup of the tube Tilt the client's nose upward Instruct the client to lower the head and swallow
An older adult patient who has been living at home alone is diagnosed with parotitis. What causative bacteria does the nurse suspect is the cause of the parotitis?
Staphylococcus aureus
A client has had a gastrostomy tube inserted. What does the nurse anticipate the initial fluid nourishment will be after the insertion of the gastrostomy tube?
Sterile water at 30 mL/hr
The nurse is inserting a sump tube in a patient with Crohn's disease who is suspected of having a bowel obstruction. What does the nurse understand is the benefit of the gastric (Salem) sump tube in comparison to some of the other tubes?
The tube is radiopaque
A client has a new order for metoclopramide. What extrapyramidal side effect should the nurse assess for in the client?
Uncontrolled rhythmic movements of the face or limbs
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?
Urine output that decreased from 60 to 40 mL/hr Heart rate that increased from 82 to 98 beats/min within 2 hours Fluid output of 2150 mL and total fluid intake of 2000 mL for the past 24 hours
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
Wear a face mask during dressing changes
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?
Weight the client every day Check the blood glucose level every 6 hours Document intake and output
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
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 enzymes and sodium bicarbonate
The client is experiencing swallowing difficulties and is now scheduled to receive a gastric feeding. The client has the following oral medications prescribed: furosemide, digoxin, enteric coated aspirin, and vitamin E. The nurse would withhold which medication?
enteric coated aspirin
The nurse recognizes that medium-length nasoenteric tubes are used for
feeding
Which venous access device can be used for less than 6 weeks in clients requiring parenteral nutrition?
nontunneled catheters
Hickman and Groshong are examples of which type of central venous access device?
tunneled central catheters
A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. She should:
turn the client on his left side and place the bed in Trendelenburg's position