Chapter 44: Digestive and Gastrointestinal Treatment Modalities 3

Auscultate lung sounds

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?

Notify the healthcare provider.

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 priorityaction by the nurse?

Ensure availability of an infusion pump Ensur completion of baseline monitoring of the complete blood count (CBC) and chemistry panel Place a 1.5-micron filter on the tubing

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.

Use semi-Fowler position during, and 60 minutes after, an intermittent feeding.

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?

diaphoresis, vomiting, and diarrhea.

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?

Assess patency of the NG tube.

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?

turn the client on his left side and place the bed in Trendelenburg's position.

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:

225 mL

A nurse measures the residual gastric volume of a patient receiving intermittent tube feedings. The patient's last residual volume was 250 mL. Which finding would lead the nurse to notify the physician?

Cranberry juice

A nurse providing care to a patient who is receiving nasogastric tube feedings finds that the tube is clogged. Which of the following would be least appropriate to use to unclog the tube?

Shakiness Tachycardia Weakness Confusion

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? Select all that apply.

"I will be lying on my back but my legs will be higher than my head."

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?

Clamp the catheter.

If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?

Document intake and output. Check blood glucose level every 6 hours. Weigh the client every day.

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.

30 minutes

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?

nontunneled central catheter.

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

feeding

The nurse recognizes that medium-length nasoenteric tubes are used for

nontunneled catheters

Which venous access device can be used for less than 6 weeks in clients requiring parenteral nutrition?

tunneled central catheters

Hickman and Groshong are examples of which type of central venous access device?

Compares exposed tube length with original measurement Visually assesses the color of the aspirate Checks the pH of the gastric contents

A client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement (select all options that apply):

Elevate the head of the bed to 45 degrees.

The nurse is to administer a cyclic feeding through a gastric tube. It is most important for the nurse to