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The nurse is to discontinue a nasogastric tube that had been used for decompression. The first thing the nurse does is |
a) Flush with 10 mL of water. Explanation: 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withdraws the tube gently for 6 to 8 inches until the tip reaches the esophagus, and then the remainder of the tube is withdrawn rapidly from the nostril.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. pg.1219 |
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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? a) The potential for aspiration |
a) The potential for aspiration Explanation: 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. pg.1219 |
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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: a) Liver function tests |
c) Fasting blood glucose level Explanation: 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. pg.1221 |
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The patient is on a continuous tube feeding. The tube placement should be checked every a) hour. |
c) shift. Explanation: Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding. Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities. Checking for placement every 12 or 24 hours does not meet the standard of care due the patient receiving continuous tube feedings pg.1217 |
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Which of the following is caused by improper catheter placement and inadvertent puncture of the pleura? a) Air embolism |
b) Pneumothorax Explanation: 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. pg.1231 |
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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? a) Nasogastric tube |
d) Gastrostomy tube Explanation: 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. pg.1214 |
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The nurse is to insert a postpyloric feeding tube. One way that the nurse can aid in placement past the pylorus is to a) Assist the client to drink 8 ounces of water. |
b) Administer prescribed metoclopramide (Reglan). Explanation: 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. pg.1216 |
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Initially, which diagnostic should be completed following placement of a NG tube? a) X-ray |
a) X-ray Explanation: 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. pg.1218 |
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A patient has just had a nasogastric (NG) tube inserted and the nurse is waiting for verification of placement of the tube prior to starting tube feedings. Which is the best method of verification the nurse should use for determining new NG tube placement? a) Observing gastric aspirate |
d) X-ray confirmation Explanation: Radiologic identification of tube placement in the stomach is the most reliable method. Gastric fluid may be grassy green, brown, clear, or odorless, whereas an aspirate from the lungs may be off-white or tan. Hence, checking aspirate is not the best method of determining NG tube placement in the stomach. Gastric pH values are typically lower or more acidic than that of the intestinal or respiratory tract, but not always. Air auscultation is not a reliable method for determining NG tube placement in the stomach when used alone. pg.1216 |
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Which of the following is the gold standard for assessing placement of a nasogastric (NG) tube for the patient receiving feedings? a) Use of capnographic device |
d) X-ray Explanation: The gold standard for verifying placement of a blindly inserted tube is radiographic or X-ray confirmation. X-ray confirmation is necessary if the patient will be receiving feedings or medications through the tube. When the tube is used to remove air or fluid and not for instillation, the nurse can use a combination of visually assessing the aspirate, testing its pH, and using capnographic devices to initially determine placement. pg.1217 |
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The patient is on a continuous tube feeding. How often should the tube placement be checked? a) Every hour |
c) Every shift Explanation: Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding. Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities. Checking for placement every 12 or 24 hours does not meet the standard of care due the patient receiving continuous tube feedings. pg.1216 |
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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 a) give the tube feeding. |
b) reassess the residual gastric content in 1 hour. Explanation: 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. pg.1221 |
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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? a) 6 |
b) 4 Explanation: 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. pg.1218 |
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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? a) Pulmonary complications |
b) Fluid volume deficit Explanation: Symptoms of fluid volume deficit include dry skin and mucous membranes, decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate. pg.1219 |
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The nurse on an evidence-based practice council is making recommendations to ensure patency of nontunneled central venous lines. The nurse recommends that daily saline and diluted heparin flushes be used in which of the following situations? a) Before drawing blood |
c) Daily when not in use Explanation: Daily instillation of normal saline and dilute heparin flush when a nontunneled central catheter is not in use will maintain the line’s patency. Continuous infusion maintains the patency of the line. Normal saline and heparin flushes should be used after each time blood is drawn in order to prevent clotting of blood within the line. Normal saline and heparin flush are not needed when a line is being discontinued. pg.1229 |
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The primary source of microorganisms for catheter-related infections include the skin and which of the following? a) IV fluid bag |
b) Catheter hub Explanation: 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. pg.1231 |
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The nurse checks residual content before each intermittent tube feeding. When should the patient be reassessed? a) When the residual is greater than 200 mL |
a) When the residual is greater than 200 mL Explanation: Although a residual volume of 200 mL or greater is generally considered a cause for concern in patients at high risk for aspiration, feedings do not necessarily need to be withheld in all patients. pg.1222 |
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The client is experiencing swallowing difficulties and is now scheduled to receive a gastric feeding. She has the following oral medications prescribed: furosemide (Lasix), digoxin, enteric coated aspirin (Ecotrin), and vitamin E. The nurse withholds a) enteric coated aspirin |
a) enteric coated aspirin Explanation: Simple compressed tablets (furosemide, digoxin) may be crushed and dissolved in water. Soft gelatin capsules filled with liquid (vitamin E) may be opened, and the contents squeezed out. Enteric coated tablets (enteric coated aspirin) are not to be crushed and a change in the form of the medications is required. pg.1223 |
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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 Explanation: 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. pg.1215 |
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A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. It is best for the nurse to a) Place the nasogastric tube to the level of the esophagus. |
c) Notify the surgeon about the tube’s removal. Explanation: 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. pg.1219 |
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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? a) 60 minutes |
c) 30 minutes Explanation: Tube feedings administered via intermittent gravity drip should be administered over 30 minutes or longer. pg.1220 |
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The nurse is monitoring a patient with nasoenteric intubation. The nurse contacts the physician when which of the following is noted? a) Blood pressure 118/72 |
d) Urinary output 20 mL/hr Explanation: 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. pg.1219 |
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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? a) Miller-Abbott tube |
b) Levin tube Explanation: 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. pg.1215 |
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The nurse is preparing to administer all of a patient’s medications via feeding tube. The nurse consults the pharmacist and/or physician when the nurse notes on the patient’s medication administration record which of the following types of oral medication? a) Enteric-coated tablets |
a) Enteric-coated tablets Explanation: 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. pg.1223 |
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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? a) Aspirating for residual contents every 4 to 8 hours. |
b) Keeping the client in a semi-Fowler’s position at all times. Explanation: 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. pg.1219 |
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The most significant complication related to continuous tube feedings is a) a disturbance in the sequence of intestinal and hepatic metabolism. |
c) the potential for aspiration, Explanation: 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. pg.1219 |
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A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to a) Auscultate lung sounds every 4 hours. |
a) Auscultate lung sounds every 4 hours. Explanation: 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. pg.1219 |
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A nurse prepares a patient for insertion of a nasoenteric tube. What position should the nurse place the patient in? a) Flat in bed |
d) In high-Fowler’s position Explanation: During insertion, the patient usually sits upright (high-Fowler’s position) with a towel or other protective barrier spread in a biblike fashion over the chest. pg.1216 |
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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 Explanation: 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. pg.1228 |
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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 a) Coiling in the client’s mouth |
c) Inserted into the lungs Explanation: 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. pg.1216 |
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The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance? |
260 Explanation: 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. pg.1219 |
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A nurse suspects that a patient is developing rebound hypoglycemia secondary to parenteral nutrition being discontinued too rapidly. Which of the following would support the nurse’s suspicions? Select all that apply. a) Weakness |
f) Shakiness e) Tachycardia a) Weakness b) Confusion Explanation: Signs and symptoms of rebound hypoglycemia include weakness, faintness, sweating, shakiness, feeling cold, confusion, and increased heart rate. pg.1230 |
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To ensure patency of central venous line ports, diluted heparin flushes are used in which of the following situations? a) Daily when not in use |
a) Daily when not in use Explanation: 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. pg.1231 |
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Rebound hypoglycemia is a complication of parenteral nutrition caused by which of the following? a) Feedings stopped too abruptly |
a) Feedings stopped too abruptly Explanation: 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. pg.1230 |
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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? a) Slowed heart beat |
c) Diarrhea Explanation: 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. pg.1220 |
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Hickman and Groshong are examples of which type of central venous access device? a) Nontunneled central catheter |
c) Tunneled central catheters Explanation: 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 the hospital, long-term care, or the home setting. pg.1230 |
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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: a) constipation, dehydration, and hypercapnia. |
c) diaphoresis, vomiting, and diarrhea. Explanation: 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. pg.1223 |
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Which of the following medications requires the nurse to contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Soft gelatin capsules filled with liquid |
b) Enteric-coated tablets Explanation: 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. pg.1223 |
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The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly? a) Tape the tube to the head of the bed to avoid dislodgement. |
c) Keep the vent lumen above the patient’s waist to prevent gastric content reflux. Explanation: The blue vent lumen should be kept above the patient’s waist to prevent reflux of gastric contents through it; otherwise, it acts as a siphon. pg.1215 |
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Semi-Fowler’s position is maintained for at least which timeframe following completion of an intermittent tube feeding? a) 2 hours |
b) 1 hour Explanation: 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. pg.1219 |
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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? a) The tube is radiopaque. |
a) The tube is radiopaque. Explanation: The gastric (Salem) sump tube is a radiopaque (easily seen on x-ray), clear plastic, double-lumen nasogastric tube. pg.1215 |
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A nurse is caring for a client with a long-term central venous catheter. Which care principle is correct? a) If the needle becomes contaminated before accessing the port, clean the needle with povidone-iodine solution. |
b) Clean the port with an alcohol pad before administering I.V. fluid through the catheter. Explanation: 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. pg.1232 |
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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 a) Change the transparent dressing every 3 days. |
d) Wear a face mask during dressing changes. Explanation: 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. pg.1229 |
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The nurse is inserting a nasogastric tube and the patient begins coughing and is unable to speak. What does the nurse suspect has occurred? a) The nurse has inadvertently inserted the tube into the trachea. |
a) The nurse has inadvertently inserted the tube into the trachea. Explanation: To ensure patient safety, it is essential to confirm that the tube has been placed correctly. The tube tip may be in the esophagus, stomach, or small intestine, or inadvertently inserted in the lungs, most commonly in the right main bronchus. Inappropriate placement may occur in patients with decreased levels of consciousness, confused mental states, poor or absent cough and gag reflexes, or agitation during insertion. pg.1216 |
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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? a) Loose, watery stools |
a) Loose, watery stools Explanation: 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. pg.1233 |
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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): a) Cover insertion site with a transparent dressing that is changed daily. |
b) Weigh the client every day. e) Check blood glucose level every 6 hours. c) Document intake and output. Explanation: 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. pg.1228 |
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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: a) No land line; cell phone available and taken by family member during working hours |
a) No land line; cell phone available and taken by family member during working hours Explanation: 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. pg.1232 |
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A client is recovering from percutaneous endoscopic gastrostomy (PEG) tube placement. The nurse a) Maintains a gauze dressing over the site for 3 days |
b) Administers an initial bolus of 50 mL water Explanation: The first fluid nourishment may consist of water, saline, or 10% dextrose. This may be administered as a bolus of 30 to 60 mL. By the second day, formula feeding may begin. A gauze dressing is applied between the tube insertion site and the gastrostomy tube. The dressing is changed daily or as needed. The nurse gently manipulates the stabilizing disk daily to prevent skin breakdown. pg.1226 |
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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? a) Administer the feeding at a warm temperature to decrease peristalsis. |
b) Administer the feeding with the patient in semi-Fowler’s position to decrease transit time influenced by gravity. Explanation: 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. pg.1223 |
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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? a) Spray the oropharynx with an anesthetic spray. |
c) Allow the patient to sip water as the tube is being inserted. Explanation: During insertion, the patient usually sits upright with a towel or other protective barrier spread in a biblike fashion over the chest. The nostril may be swabbed or the oropharynx sprayed with an anesthetic agent to numb the nasal passage and suppress the gag reflex. The tip of the patient’s nose is tilted upward, and the tube is aligned to enter the nostril. When the tube reaches the nasopharynx, the patient is instructed to lower the head slightly and, if able, to begin to swallow as the tube is advanced. The patient may also be encouraged to sip water through a straw to facilitate advancement of the tube if this action is not contraindicated. pg.1216 |
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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? a) Lower the head of the bed. |
d) Monitor the feeding closely. Explanation: 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. pg.1221 |
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The client has just had a central line inserted for parenteral nutrition. The client is awaiting transport to the Radiology Department for catheter placement verification. The client reports feeling anxious. Respirations are 28 breaths/minute. The first action of the nurse is a) Auscultate lung sounds. |
a) Auscultate lung sounds. Explanation: Following placement of a central line, the client is at risk for a pneumothorax. The client’s report of anxiety and increased respiratory rate may be the first signs and symptoms of a pneumothorax. The nurst first assesses the client by auscultating lung sounds. Other actions include placing the client in Fowler’s position and consulting with the healthcare provider about findings. pg.1231 |
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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? a) 120 mL |
d) 80 mL Explanation: 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.) pg.1223 |
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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? a) "It is a vent that prevents backflow of the secretions." |
a) "It is a vent that prevents backflow of the secretions." Explanation: 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. pg.1215 |
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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? a) Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. |
a) Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. Explanation: Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely. pg.1224 |
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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? a) Excess fluid volume |
a) Excess fluid volume Explanation: 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. pg.1219 |
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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? a) Peripherally inserted central catheter |
d) Nontunneled central catheter Explanation: 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. pg.1229 |
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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 a) Discusses with the nutritionist about increasing the osmolality of the feeding |
d) Consults with the physician about decreasing the feeding to half-strength Explanation: The osmolality of normal body fluids is 300 mOsm/kg. A feeding with a higher osmolality may cause dumping syndrome. The client may report a feeling of fullness, nausea, or both and may exhibit diarrhea, hypotension, and tachycardia. The nurse needs to take steps to prevent dumping syndrome. Increasing the amount of the feeding, administering the feeding at an extreme temperature, or increasing the osmolality of the feedings will continue dumping syndrome. The nurse needs to decrease the osmolality of the feeding as in administering a half-strength solution. pg.1220 |
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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 a) Attaches the fat emulsion tubing to a Y connector close to the infusion site |
a) Attaches the fat emulsion tubing to a Y connector close to the infusion site Explanation: 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. pg.1228 |
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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? a) Base of the neck |
b) Tip of patient’s nose Explanation: 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. pg.1216 |
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A nurse is preparing to perform a dressing change to the site of a patient’s central venous catheter used for parenteral nutrition. Which equipment and supplies would the nurse need to gather? Select all that apply. a) Sterile gauze pads |
b) Masks c) Skin antiseptic f) Alcohol wipes a) Sterile gauze pads Explanation: When preparing to perform a dressing change to a central venous access site, sterile technique is essential. The nurse would need to gather masks (for self and the patient) to reduce the possibility of airborne contamination, sterile gloves, skin antiseptic such as tincture of 2% iodine or chlorhexadine, sterile gauze to clean the area, sterile water or saline to clean the area after cleaning with the skin antiseptic, and alcohol wipes to clean the catheter ports. Extension set tubing is not routinely changed with dressing or tubing changes. Sterile, not clean, gloves are used. pg.1229 |
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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? a) Have the patient mix it with the feeding formula after crushing the tablet. |
b) Check with the pharmacy for an alternative formulation for the drug. Explanation: 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. pg.1223 |
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When assessing whether a patient is a candidate for home parenteral nutrition, which of the following would be important to address? Select all that apply. a) Health status |
a) Health status b) Family support c) Telephone access d) Motivation for learning Explanation: Ideal candidates for home parenteral nutrition are patients who have a reasonable life expectancy after return home, have a limited number of illnesses other than the one that has resulted in the need for parenteral nutrition, and are highly motivated and fairly self-sufficient. Additional areas to consider include the patient’s ability to learn, availability of family interest and support, adequate finances, and the physical plan of the home including access to water, electricity, refrigeration, and telephone. The patient’s marital status is not important. pg.1232 |
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Which of the following is the best noninvasive means of unclogging tubes? a) Cranberry juice |
d) Pancreatic enzymes and water Explanation: Cola and cranberry juice have historically been recommended as effective, noninvasive means of unclogging tubes. Evidence indicates that a mixture of pancreatic enzymes and water is superior in restoring the patency of feeding tubes. pg.1218 |
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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? (Select all that apply.) a) Until bowel sound is present |
a) Until bowel sound is present e) Until flatus is passed d) Until peristalsis is resumed Explanation: Before removing an enteral tube, the nurse may intermittently clamp it for a trial period of several hours to ensure that the patient does not experience nausea, vomiting, or distention. Before any tube is removed, it is flushed with 10 mL of water or normal saline to ensure that it is free of debris and away from the gastric lining. Gloves are worn when removing the tube. The tube is withdrawn gently and slowly for 15 to 20 cm (6 to 8 in) until the tip reaches the esophagus; the remainder is withdrawn rapidly from the nostril. If the tube does not come out easily, force should not be used, and the problem should be reported to the primary provider. As the tube is withdrawn, it is concealed in a towel to prevent secretions from soiling the patient or nurse. After the tube is removed, the nurse provides oral hygiene. pg.1219 |
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The primary source of microorganisms for catheter-related infections are the skin and a) IV fluid bag. |
d) catheter hub. Explanation: 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. pg.1232 |
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A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate? a) Have someone go to the pharmacy to obtain the new solution. |
c) Hang a solution of dextrose 10% and water until the new solution is available. Explanation: The infusion rate of the solution should not be increased or decreased; if the solution is to run out, a solution of 10% dextrose and water is used until the next solution is available. Having someone go to the pharmacy would be appropriate, but there is no way to determine if the person will arrive back before the solution runs out. Starting another infusion would be inappropriate. Additionally, the infusion needs to be maintained through the central venous access device to maintain patency. pg.1232 |
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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. a) Daily transparent dressing changes |
d) Daily weights b) Intake and output monitoring c) Calorie counts for oral nutrients Explanation: 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. pg.1233 |
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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? a) 30-mL |
a) 30-mL Explanation: 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. pg.1222 |
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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? a) 1 |
c) 6 Explanation: Determining the pH of the tube aspirate is a more accurate method of confirming tube placement than is maintaining tube length or visually assessing tube aspirate. The pH method can also be used to monitor the advancement of the tube into the small intestine. The pH of gastric aspirate is acidic (1 to 5), typically less than 4. The pH of intestinal aspirate is approximately 6 or higher, and the pH of respiratory aspirate is more alkaline ( ? 6). pg.1218 |
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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 a) Stop the continuous feeding |
c) Notify the physician Explanation: The second residual volume is greater than the first. When excessive residual volume (more than 200 mL) of a nasogastric feeding occurs twice, the nurse notifies the physician. The nurse does not discard the aspirate because the client has partially digested this fluid. After discussing with the physician, the nurse may stop the continuous feeding for some time or decrease the rate of infusion. pg.1222 |
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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 Explanation: 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. pg.1232 |
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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? a) Commercial enzyme product |
c) Cranberry juice Explanation: To unclog a feeding tube, air insufflation, digestive enzymes mixed with warm water, or a commercial enzyme product could be used. Cola and cranberry juice are no longer advocated for use in clearing a clogged tube. pg.1218 |
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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? a) 10 p.m. to 12 a.m. |
c) 6 p.m. to 8 p.m. Explanation: The recommendation is to irrigate the feeding tube of patients receiving continuous tube feedings every 4 to 6 hours. For this patient, the nurse would irrigate the tube next at 6 p.m. to 8 p.m. pg.1222 |
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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? a) Cola mixed with cranberry juice |
b) Digestive enzymes and sodium bicarbonate Explanation: 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. pg.1218 |
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After teaching a patient about the procedure for inserting a nontunneled central catheter, the nurse determines that the patient has understood the instructions based on which of the following statements? a) "I need to keep my head turned directly toward you and the physician." |
d) "I will be lying on my back but my legs will be higher than my head." Explanation: For catheter insertion, the patient is in the Trendelenburg position to produce dilation of the neck and shoulder vessels, which makes entry easier and decreases the risk of air embolus. The patient is instructed to turn the head away from the site of the venipuncture and to remain motionless while the catheter is inserted and the site is dressed. During insertion, until the syringe is detached from the needle and the catheter is inserted, the patient may be asked to perform the Valsalva maneuver, not take long, slow, deep breaths. Typically a transparent dressing is applied over the insertion site. pg.1229 |
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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? a) 200 mL |
b) 225 mL Explanation: If a residual volume greater than 200 mL is obtained twice, the nurse would need to notify the physician. A single residual volume of 200 mL or more does not indicate a need to withhold a feeding. Feedings may be continued in patients as long as there is close monitoring of gastric residual volume trends, x-ray study results, and the patient’s physical status. pg.1222 |
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