Chapter 44 Med-Surg PREPU

A nurse administered a full strength feeding with an increased osmolality through a jejunostomy tube to a client. Immediately following the feeding, the client expelled a large amount of liquid brown stool and exhibited a blood pressure of 86/58 and pulse rate of 112 beats/min. The nurse

Consults with the physician about decreasing the feeding to half-strength

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 the nurse's hands Measure the length of the tube that will be inserted Apply water-soluble lubricant to the tip of the tube Tilt the client's nose upward Instruct the client to lower the head and swallow

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/h

A nurse is interviewing a patient to determine suitability for home parenteral nutrition. Which patient statement would alert the nurse to a potential problem?

"I have a telephone, but it has been shut off because my bill is overdue."

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."

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

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 (normal: 1-5)

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.

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 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. When an NG tube is no longer patent, stomach contents collect in the stomach, giving the client a sensation of fullness. The nurse should begin by assessing patency of the NG tube. The nurse can measure abdominal girth, auscultate bowels, and assess vital signs, but she should check NG tube patency first to help relieve the client's discomfort.

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 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.

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

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

Clamp the catheter

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 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

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 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

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.

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

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.

When assessing whether a client is a candidate for home parenteral nutrition, what would be important to address? Select all that apply.

Motivation for learning Telephone access Health status Family support

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. - 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.

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.

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 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

When preparing to insert a nasogastric tube, the nurse determines the length of the tube to be inserted. The nurse places the distal tip of the tube at which location?

Tip of patient's nose

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 BS (168)

Rebound hypoglycemia is a complication of parenteral nutrition caused by

feedings stopped too abruptly.

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

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

hub

The nurse conducts discharge education for a client who is to go home with parenteral nutrition (PN). The nurse determines the client understands the education when the client indicates a sign and/or symptom of metabolic complications is

loose, watery stools - Signs and symptoms of metabolic complications from PN include neuropathies, changes in mental activity, diarrhea, nausea, skin changes, and decreased urine output.

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

pneumothorax

The most significant complication related to continuous tube feedings is

risk for aspiration

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

shift

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

urinary output 20 mL/hr

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?

FVD

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.

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.

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

When the residual is greater than 200 mL

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? Select all that apply.

Fluid output of 2150 mL and total fluid intake of 2000 mL for the past 24 hours Heart rate that increased from 82 to 98 beats/min within 2 hours Urine output that decreased from 60 to 40 mL/hr

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

Residual content is checked before each intermittent tube feeding. The patient would be reassessed if the residual, on two occasions, was:

>200 ml

The nurse prepares to administer all of a client's medications via feeding tube. The nurse consults the pharmacist and/or physician when the nurse notes which type of oral medication on the client's medication administration record?

enteric-coated tablets

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 p.m. to 8 p.m.

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 Calorie counts for oral nutrients Intake and output monitoring

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.

Diarrhea Tachycardia Diaphoresis - Dumping syndrome is manifested by hypotension, diarrhea, tachycardia, and diaphoresis. The client often reports a feeling of fullness, nausea, and vomiting. Because of the rapid movement of water to the stomach and intestines, bowel sounds would most likely be increased.

Which tube is a nasoenteric feeding tube?

Dobbhoff - Nasogastric tubes include Levin, a gastric sump, and Sengstaken-Blakemore tubes.

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.

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.

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