Chapter 45

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

Initially, which diagnostic should be completed following placement of a NG tube?

x-ray

The nurse is to discontinue a nasogastric tube that had been used for decompression. The first thing the nurse does is

Flush with 10 mL of water.

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

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

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

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?

Gastrostomy tube

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 nurse prepares a patient for insertion of a nasoenteric tube. What position should the nurse place the patient in?

In a high-Fowler's position

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

Catheter hub

Rebound hypoglycemia is a complication of parenteral nutrition caused by which of the following?

Feedings stopped too abruptly

To ensure patency of central venous line ports, diluted heparin flushes are used in which of the following situations?

Daily when not in use

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

Nursing students are reviewing information about various gastrointestinal tubes. They demonstrate a need for additional study when they identify which of the following as a nasogastric tube?

Dobbhoff

Which of the following medications requires the nurse to contact the pharmacist in consultation when the patient receives all oral medications by feeding tube?

Enteric coated tablets

A nurse is caring for a patient receiving parenteral nutrition at home. The patient was discharged from the acute care facility 4 days ago. Which of the following would the nurse include in the patient's plan of care? Select all that apply.

• Calorie counts for oral nutrients • Intake and output monitoring • Daily weights

The nurse is monitoring a patient with nasoenteric intubation. The nurse contacts the physician when which of the following is noted?

Urinary output 20 mL/hr

The nurse inserts a nasoduodenal tube for feeding of the client. To check best for placement, the nurse

Verifies location with an abdominal x-ray

The patient is on a continuous tube feeding. The tube placement should be checked every

shift

The most significant complication related to continuous tube feedings is

the potential for aspiration,

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

Greater than 200 mL.

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.

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 makes a recommendation when noting the following:

No land line; cell phone available and taken by family member during working hours

A client is receiving continuous tube feedings at 75 mL/hr. The nurse has checked the residual volume 4 hours ago as 250 mL. The nurse now assesses the residual volume as 325 mL. The first action of the nurse is to

Notify the physician

A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. It is best for the nurse to

Notify the surgeon of the tube's removal

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 who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for:

diaphoresis, vomiting, and diarrhea.