Med Surg Prep U Ch.25

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

260 *Intake includes all the components listed in the intake column, which amounts to 710 mL. The output, which is the urine of 450 mL, is subtracted from the total intake. This leaves 260 mL as a positive fluid balance

(see full question) A patient is receiving a continuous tube feeding via an open delivery system. The patient is to receive 480 mL in 24 hours. The maximum amount of formula in the bag should not exceed which amount?

80 mL *When using an open delivery system, bacterial contamination is possible. Therefore, the amount of feeding formula in the bag should never exceed what should be infused in a 4-hour period. In this case that amount would be 80 mL. (480 mL divided by 24 hours equals 20 mL per hour. 20 mL times 4 hours equals 80 mL.)

What is the pH of gastric aspirate?

Acidic *The pH of gastric aspirate is acidic (1 to 5).

The nurse is to insert a postpyloric feeding tube. One way that the nurse can aid in placement past the pylorus is to

Administer prescribed metoclopramide (Reglan). *Metoclopramide (Reglan) is administered to increase peristalsis of the feeding tube into the duodenum. Placing the client on his right side, not the left side, helps to facilitate movement and placement. Having the client swallow or even to drink water facilitates placement of the tube past the epiglottis, not into the duodenum

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 *Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change in the form of medication is necessary for patients with tube feedings. Simple compressed tablets may be crushed and dissolved in water for patients receiving oral medications by feeding tube. Buccal or sublingual tablets are absorbed by mucous membranes and may be given as intended to the patient undergoing tube feedings. The nurse may make an opening in the capsule and squeeze out contents for administration by feeding tube.

(see full question) 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 telephone is necessary for the client receiving PN for emergency purposes. Water, refrigeration, and electricity are available, even if the circumstances are not optimal.

A patient is to receive parenteral nutrition. The duration of therapy is planned for 4 weeks. The nurse develops a teaching plan for the patient to prepare for insertion of which of the following as most likely?

Nontunneled central catheter *Because therapy will last fewer than 6 weeks, the patient will most likely receive a nontunneled central catheter. Peripherally inserted central catheters are used for intermediate-term (several days to months) therapy sessions, while tunneled catheters and implanted ports are used for long-term therapy

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 maintaining a central venous catheter should change the dressing every 72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the nurse should use sterile technique to clean around the site in accordance with facility policy. After the cleaning solution has dried, the nurse should cover the site with a transparent semipermeable dressing. A nurse who notes drainage on a wound dressing should draw a circle around the moist spot and note the date and time. She should notify the physician if she observes any catheter-related complications. Only a nurse with the appropriate qualifications may remove a central venous catheter, and a moist or loose dressing isn't a reason to remove the catheter

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):

The nasogastric tube must be checked every shift for placement when a client is receiving continuous feedings. Recommended methods are comparing the exposed nasogastric tube length to the original measurement, visually assessing the color of the aspirate, and checking the pH of the gastric contents with a pH sensor. Confirming tube placement with radiology is costly and may be performed at the time of initial insertion. Inserting tap water through the nasogastric tube does not verify placement.

The nurse is teaching an unlicensed caregiver about bathing patients who are receiving tube feedings. Which of the following is the most significant complication related to continuous tube feedings?

The potential for aspiration *Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the patient receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis

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

Tunneled central catheters *Hickman and Groshong catheters are examples of tunneled central catheters. MediPort is an implanted port. A percutaneous subclavian Arrow is an example of a nontunneled central catheter. A PICC line is used for intermediate-term IV therapy for hospital, long-term care, or the home setting

Nursing students are reviewing information about parenteral nutrition and indications for use. They demonstrate understanding of the material when they identify which patients as appropriate candidates for parenteral nutrition? Select all that apply.

• Child with short bowel syndrome • Middle-aged man with acute pancreatitis • Man with two-thirds of his colon removed *Indications for parenteral nutrition include short bowel syndrome, acute pancreatitis, and extensive bowel surgery. Gastroenteritis and superficial burns would not be indications for parenteral nutrition

A patient has had a gastrostomy tube inserted. What does the nurse anticipate the initial fluid nourishment will be after the insertion of the gastrostomy tube?

10% glucose and tap water *The first fluid nourishment is administered soon after tube insertion and can consist of a sterile water or normal saline flush of at least 30 mL. Tap water may be used during medication administration or tube feedings

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 blue part of the Salem sump tube vents the larger suction-drainage tube to the atmosphere and, when kept above the patient's waist, prevents reflux of gastric contents through it. Otherwise it acts as a siphon. A gauge on the suction device regulates the pressure of the device. The tube has markings on it to aid in measurement.

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 *Typically a bolus tube feeding of 300 to 500 mL requires about 10 to 15 minutes to complete.

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 *The patient receives 30 mL every 6 hours. So over a 24-hour period, the patient would receive 4 irrigations. 4 times 30 mL equals 120 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 *The output measured includes the two 20 mL irrigations. To determine the actual output, the nurse would subtract the amount of irrigation used (in this case 40 mL total) from the total output (in this case 320 mL) and arrive at an output of 280 mL.

The nurse is administering a tube feeding to a patient via intermittent gravity drip method. The nurse should administer the feeding over at least which period of time?

30 minutes *Tube feedings administered via intermittent gravity drip should be administered over 30 minutes or longer

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 *When small-bore feeding tubes for continuous tube feedings are used and irrigated after administration of medications, a 30-mL or larger syringe is necessary, because the pressure generated by smaller syringes could rupture the tube

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 *Gastric secretions are acidic and have a pH ranging from 1 to 5. Intestinal aspirate is typically 6 or higher; respiratory aspirate is more alkaline, usually 7 or greater.

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 *The client's weight of 154 pounds is equal to 70 kg. The client is to receive 0.6 g of protein for each 1 kg of body weight. 0.6 g/kg x 70 kg = 42 grams.

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). The nurse

Attaches the fat emulsion tubing to a Y connector close to the infusion site *An intravenous fat emulsion is attached to a Y connector close to the infusion site. The fat emulsion is administered simultaneously with the parenteral nutrition admixture. A separate peripheral IV site is not necessary. The fat emulsion is not administered through a filter

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. *Pulmonary complications may occur as a result of nasogastric intubation. It is a high priority according to Maslow's hierarchy of needs and takes a higher priority over assessing the nose, changing nasal tape, or applying a water-based lubricant

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

Clamp the catheter. *If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp. If a clamp isn't available, the nurse may place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension set and restart the infusion. Calling the physician, applying a dry sterile dressing to the site, and telling the client to take a deep breath aren't appropriate interventions at this time.

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 *The nurse should clean the port with an alcohol pad before administering I.V. fluid through the catheter to prevent microorganisms from entering the bloodstream. Using clean technique when accessing the port with a needle, cleaning the needle with a povidone-iodine solution, or reusing a needle would break sterile technique

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

Notify the surgeon about the tube's removal. *If the nasogastric tube is removed accidently in a client who has undergone esophageal or gastric surgery, it is usually replaced by the physician. Care is taken to avoid trauma to the suture line. The nurse will not insert the tube to the esophagus or to the stomach in this situation. The nurse needs to do more than just document its removal. The nurse needs to notify the physician who will make a determination of leaving out or inserting a new nasogastric tube.

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

Daily when not in use *Daily instillation of dilute heparin flush when a port is not in use will maintain the port. Continuous infusion maintains the patency of each port. Heparin flushes are used after each intermittent infusion. Heparin flushes are used after blood drawing in order to prevent clotting of blood within the port. Heparin flush of ports is not necessary if a line is to be discontinued

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 *Clients with a gastrojejunostomy are at risk for developing the dumping syndrome when they begin to take solid food. This syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramps, and diarrhea, which result from the rapid emptying (dumping) of large amounts of hypertonic chyme (a liquid mass of partly digested food) into the jejunum. This concentrated solution in the gut draws fluid from the circulating blood into the intestine, causing hypovolemia. The drop in blood pressure can produce syncope. As the syndrome progresses, the sudden appearance of carbohydrates in the jejunum stimulates the pancreas to secrete excessive amounts of insulin, which in turn causes hypoglycemia

The nurse is attempting to unclog a patient's feeding tube. Attempts with warm water agitation and milking the tube have been unsuccessful. The nurse uses evidence-based practice principles when she then uses which of the following to unclog the tube?

Digestive enzymes and sodium bicarbonate *The nurse should attempt to unclog the tube with digestive enzymes activated with sodium bicarbonate. Although historically both cranberry juice and cola have sometimes been used to unclog feeding tubes, evidence has shown that their acidic nature worsens the clog by causing precipitation of proteins. Meat tenderize diluted with saline is not applicable.

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 *The patient's intake and output record reflects a greater intake than output, suggesting excess fluid volume. No information suggests that the patient's nutritional balance is at risk, even with nasogastric tube feedings. Deficient fluid volume would be appropriate if the patient's output exceeded input. No information indicates that the patient is experiencing difficulty with urination

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 *An adverse reaction to tube feedings is an elevated blood glucose level. The physical assessment data and renal function and liver function studies are normal.

For what are medium-length nasoenteric tubes are used?

Feeding *Placement of the tube must be verified prior to any feeding. A gastric sump and nasoenteric tube are used for gastrointestinal decompression. Nasoenteric tubes are used for feeding. Gastric sump tubes are used to decompress the stomach and keep it empty.

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

Feedings stopped too abruptly *Rebound hypoglycemia occurs when the feedings are stopped too abruptly. Hyperglycemia is caused by glucose intolerance. Fluid overload is caused by fluids infusing too rapidly. An air embolism can occur from a cap missing on a port

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 *Symptoms of fluid volume deficit include dry skin and mucous membranes, decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate.

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. *Before a nasogastric tube is removed, the nurse flushes the tube with 10 mL of water or normal saline to ensure that the tube is free of debris and away from the gastric tissue. The tape keeps the tube in the correct position while flushing is occurring and is then removed from the nose. The nurse then withdraws the tube gently for 6 to 8 inches until the tip reaches the esophagus, and then the remainder of the tube is withdrawn rapidly from the nostril. After the tube is removed, the nurse provides oral hygiene.

A nurse prepares a patient for insertion of a nasoenteric tube. The nurse should position the patient:

In high-Fowler's position. *The patient should sit upright with some type of protective bib-like barrier. Privacy and adequate light are necessary. The tip of the nose is tilted and the tube aligned to enter the nostril following the floor of the nose, not upward toward the nasal bridge

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 alert client may cough constantly and have difficulty with respirations when the nasogastric tube enters the lungs. The client may cough but will not have difficulty with respirations with the nasogastric tube coiling in the mouth or irritating the epiglottis. Usually if the nastogastric tube is entering the esophagus, the client will not exhibit coughing or dyspnea.

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. *With continuous tube feedings, the nurse needs to keep the client in a semi-Fowler's position at all times to reduce regurgitation and the risk for aspiration. Aspirating for residual contents helps to ensure adequate nutrition and prevent overfeeding. Administering 15 to 30 mL of water every 4 hours helps to maintain tube patency. Giving the feedings at room temperature reduces the risk for diarrhea.

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

Pneumothorax *A pneumothorax is caused by improper catheter placement and inadvertent puncture of the pleura. Air embolism can occur from a missing cap on a port. Sepsis can be caused by the separation of dressings. Fluid overload is caused by fluids infusing too rapidly.

The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also complains of unpleasant tastes and odors. Which of the following measures should be included in the client's plan of care?

Provide frequent mouth care. *Frequent mouth care helps to relieve the discomfort from dryness and unpleasant odors and tastes. It can be done with the help of ice chips and analgesic throat lozenges, gargles, or sprays. Adequate hydration is essential. If urine output is less than less than 500 mL/day, formula and additional water can be given as ordered. Keeping the feeding formula refrigerated and unopened until it is ready for use and flushing the tube with water before adding feedings are measures to protect the client from infections.

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 *Initially, an x-ray should be used to confirm placement of the nasoduodenal tube. It is the most accurate method to verify tube placement. Adding 8 to 10 inches to the length of the tube after measuring from nose to earlobe to xiphoid process is not supported, because it does not indicate that the tube will be in the correct position. Intestinal aspirate is usually clear and yellow to bile-colored. Gastric aspirate is usually cloudy and green, tan, off-white, or brown. Food particles may be present. The traditional method of injecting air through the tube while auscultating the epigastric area with a stethoscope to detect air insufflation is also an unreliable indicator.

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 Centers for Disease Control and Prevention (CDC) recommends changing central vascular access device dressings every 7 days. During dressing changes, the nurse and client wear face masks to reduce the possibility of airborne contamination. The transparent dressing allows for frequent assessments of the site. This is to be done more frequently than daily. During dressing changes, the nurse wears sterile gloves.

The nurse prepares to give a bolus tube feeding to the patient and determines that the residual gastric content is 150 cc. The priority nursing action is to

reassess the residual gastric content in 1 hour *If the gastric residual exceeds 100 cc for 2 hours in a row, the physician should be notified. One observation of a residual gastric content over 100 cc does not have to be reported to the physician. If the observation occurs two times in succession, the physician should be notified. If the amount of gastric residual exceeds 100 cc, the tube feeding should be withheld at that time. If the amount of gastric residual exceeds 100 cc, the tube feeding should be withheld at that time, but not indefinitely

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

• Intake and output monitoring • Calorie counts for oral nutrients • Daily weights *For the patient receiving parenteral nutrition at home, the nurse would obtain daily weights initially, decreasing them to two to three times per week once the patient is stable. Intake and output monitoring also is necessary to evaluate fluid status. Calorie counts of oral nutrients are used to provide additional information about the patient's nutritional status. Transparent dressings are changed weekly. Activity is encouraged based on the patient's ability to maintain muscle tone. Strict bedrest is not appropriate

A patient receiving tube feedings has prescriptions for several drugs. Which of the following drugs would the nurse expect to administer to the patient without any special preparation? Select all that apply.

• Liquid stool softener • Sublingual nitroglycerin *Liquid medications do not require any special preparation for administration via a feeding tube. Buccal or sublingual tablets are administered as prescribed. They are absorbed through the mucosa of the cheek or under the tongue and thus would not be administered through the feeding tube. Enteric-coated aspirin and sustained-release antihypertensive could not be given as is through a feeding tube. A change in formulation would be needed. An acetaminophen tablet would need to be crushed and dissolved in water before being given.

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

1 hour *The semi-Fowler's position is necessary for an NG feeding, with the patient's head elevated at least 30 to 45 degrees to reduce the risk for reflux and pulmonary aspiration. This position is maintained for at least 1 hour after completion of an intermittent tube feeding and is maintained at all times for patients receiving continuous tube feedings

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 following strategies may help prevent some of the uncomfortable signs and symptoms of dumping syndrome related to tube feeding: Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. Administer feedings at room temperature, because temperature extremes stimulate peristalsis. Administer feeding by continuous drip (if tolerated) rather than by bolus, to prevent sudden distention of the intestine. Advise the patient to remain in semi-Fowler's position for 1 hour after the feeding; this position prolongs intestinal transit time by decreasing the effect of gravity. Instill the minimal amount of water needed to flush the tubing before and after a feeding, because fluid given with a feeding increases intestinal transit time.

The nurse is caring for a patient who is at receiving continuous enteral tube feedings who is at low risk for aspiration. The nurse assesses the gastric residual volume to be 350 mL. Which of the following is the correct action by the nurse?

Monitor the feeding closely. *High residual volumes (>200 mL) should alert the nurse to monitor the patient more closely. Increasing the feeding rate will increase the residual volume. Lowering the head of the bed increases the patient's risk for aspiration

The nurse is conducting discharge education for a patient who is to go home with parenteral nutrition (PN). The nurse sees that the patient understands the education when the patient indicates which of the following is a sign and/or symptom of metabolic complications?

Loose, watery stools *When the patient indicates that loose watery stools are a sign/symptom of metabolic complications, the nurse evaluates that the patient understands the teaching of metabolic complications. Signs and symptoms of metabolic complications from PN include neuropathies, mentation changes, diarrhea, nausea, skin changes, and decreased urine output

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

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. *Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact. Regurgitation and aspiration are less likely to occur with a gastrostomy than with NG feedings

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 *A gastrostomy tube enters the stomach through a surgically created opening into the abdominal wall. A jejunostomy tube enters jejunum or small intestine through a surgically created opening into the abdominal wall. A nasogastric tube passes through the nose into the stomach via the esophagus. An orogastric tube passes through the mouth into the stomach.

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 *A nurse who suspects an air embolism should place the client on his left side and in Trendelenburg's position. Doing so allows the air to collect in the right atrium rather than enter the pulmonary system. The supine position, high-Fowler's position, and the shock position are therapeutic for other situations but not for air embolism

A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. The nurse does all of the following. Select all that apply.

• Ensures availability of an infusion pump • Ensures completion of baseline monitoring of the complete blood count (CBC) and chemistry panel • Places a 1.5-micron filter on the tubing *Parenteral nutrition with dextrose concentrations of greater than 10% should not be administered through peripheral veins. An infusion pump should always be used for administration of parenteral nutrition. Standing orders are initiated that include monitoring of CBC and chemistry panel prior to the start of parenteral nutrition. Medications should not be administered in the same IV line as the parenteral nutrition because of potential incompatabilities with the components of the nutritional solution. A special filter (1.5-micron filter) is used with parenteral nutrition.

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. *Research demonstrates that residual volumes of less than 200 mL appear to be well tolerated without risk of aspiration.

The following appears on the medical record of a male patient receiving parenteral nutrition: WBC: 6500/cu mm Potassium 4.3 mEq/L Magnesium 2.0 mg/dL Calcium 8.8 mg/dL Glucose 190 mg/dL Which finding would alert the nurse to a problem?

Glucose level *Of the values listed, only the glucose level is above normal, indicating hyperglycemia, a potential complication of parenteral nutrition.

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

Catheter hub *The primary sources of microorganisms for catheter-related infections are the skin and the catheter hub. The catheter site is covered with an occlusive gauze dressing that is usually changed every other day

A nurse is providing home care to a patient receiving intermittent tube feedings. The patient wants to take an over-the-counter allergy medication. The medication would need to be given via feeding tube because the patient 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 *Timed-release medications should not be crushed. Rather, the nurse should check with the pharmacy to see if another formulation (eg, liquid) is available that can be used safely with a feeding tube. Dissolving the tablet in water, like crushing it, would affect the drug's action, possibly releasing too much of the drug too quickly. Stating that the patient cannot take the drug anymore is inappropriate. A change in formulation or possibly a change to another drug in an appropriate formulation would be appropriate

The physician orders the insertion of a single lumen nasogastric tube. When gathering the equipment for the insertion, the nurse would select which of the following?

Levin tube *A Levin tube is a single lumen nasogastric tube. A Salem sump tube is a double lumen nasogastric tube; a Sengsten-Blakemore tube is a triple lumen nasogastric tube. A Miller-Abbott tube is a double lumen nasoenteric tube.

Before inserting a gastric or enteric tube, the nurse determines the length of tubing that will be needed to reach the stomach or small intestine. The Levin tube, a commonly used nasogastric tube, has circular markings at specific points. This tube should be inserted to 6 to 10 cm beyond what length?

The distance measured from the tip of the nose (N) to the earlobe (E) and from the earlobe to the xiphoid (X) process *Using this measurement, the nose-earlobe-xiphoid process (NEX), will prevent inserting the tube into the lower esophagus. Two other measurements are used and can be reviewed in the chapter. The average measurement for adults is 22 to 26 inches. Refer to Figure 22-8 in the text.

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

Tip of patient's nose *To measure the length of the nasogastric tube, the nurse first places the distal tip of the tubing at the tip of the patient's nose, extends the tube to the tragus of the ear, and then extends the tube straight down to the tip of the xiphoid process.

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 should notify the physician when the patient has a urinary output of 20 mL/hr as this is a decreased urinary rate. Decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate are signs and symptoms of fluid volume deficit. A heart rate of 100, BP of 118/72, and moist mucous membranes are findings that are within acceptable ranges/limits and do not indicate a fluid volume deficit

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

X-ray *Initially an X-ray should be used to confirm tube placement. Subsequently, each time liquids or medications are administered, as well as once per shift for continuous feedings, a combination of three methods is recommended: measurement of tube length, visual assessment of aspirate, and pH measurement of aspirate.

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. *The nurse must monitor for diaphoresis, vomiting, and diarrhea because these signs suggest an intolerance to the ordered enteral feeding solution. Other signs and symptoms of feeding intolerance include abdominal cramps, nausea, aspiration, and glycosuria. Electrolyte disturbances, constipation, dehydration, and hypercapnia are complications of enteral feedings, not signs of intolerance. Hyperglycemia, not hypoglycemia, is a potential complication of enteral feedings

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). The nurse performs the following actions while the client receives PN (select all that apply):

• Weigh the client every day. • Check blood glucose level every 6 hours. • Document intake and output. *When a client is receiving PN through a central line, the nurse weighs the client daily, checks blood glucose level every 6 hours, and documents intake and output. These actions are to ensure the client is receiving optimal nutrition. The nurse also performs activities to prevent infection, such as covering the insertion site with a transparent dressing that is changed weekly and/or prn and using sterile technique during catheter site dressing changes.