Brunner's Ch 44: Digestive and Gastrointestinal Treatment Modalities Flashcards
(40 cards)
A nurse is preparing to place a patients ordered nasogastric tube. How should the nurse best determine the correct length of the nasogastric tube?
A) Place distal tip to nose, then ear tip and end of xiphoid process.
B) Instruct the patient to lie prone and measure tip of nose to umbilical area.
C) Insert the tube into the patients nose until secretions can be aspirated.
D) Obtain an order from the physician for the length of tube to insert.
A) Place distal tip to nose, then ear tip and end of xiphoid process.
Tube length is traditionally determined by (1) measuring the distance from the tip of the nose to the earlobe and from the earlobe to the xiphoid process, and (2) adding up to 6 inches for NG placement or at least 8 to 10 inches or more for intestinal placement, although studies do not necessarily confirm that this is a reliable technique. The physician would not prescribe a specific length and the umbilicus is not a landmark for this process. Length is not determined by aspirating from the tube.
A patient is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube?
A) Prime the tubing with 20 mL of normal saline.
B) Keep the vent lumen above the patients waist.
C) Maintain the patient in a high Fowlers position.
D) Have the patient pin the tube to the thigh.
B) Keep the vent lumen above the patients waist.
The blue vent lumen should be kept above the patients waist to prevent reflux of gastric contents through it; otherwise it acts as a siphon. A one-way anti-reflux valve seated in the blue pigtail can prevent the reflux of gastric contents out the vent lumen. To prevent reflux, the nurse does not prime the tubing, maintain the patient in a high Fowlers position, or have the patient pin the tube to the thigh.
A patient receiving tube feedings is experiencing diarrhea. The nurse and the physician suspect that the patient is experiencing dumping syndrome. What intervention is most appropriate?
A) Stop the tube feed and aspirate stomach contents.
B) Increase the hourly feed rate so it finishes earlier.
C) Dilute the concentration of the feeding solution.
D) Administer fluid replacement by IV.
C) Dilute the concentration of the feeding solution.
Dumping syndrome can generally be alleviated by starting with a dilute solution and then increasing the concentration of the solution over several days. Fluid replacement may be necessary but does not prevent or treat dumping syndrome. There is no need to aspirate stomach contents. Increasing the rate will exacerbate the problem.
A nurse is admitting a patient to the postsurgical unit following a gastrostomy. When planning assessments, the nurse should be aware of what potential postoperative complication of a gastrostomy?
A) Premature removal of the G tube
B) Bowel perforation
C) Constipation
D) Development of peptic ulcer disease (PUD)
A) Premature removal of the G tube
A significant postoperative complication of a gastrostomy is premature removal of the G tube. Constipation is a less immediate threat and bowel perforation and PUD are not noted to be likely complications.
A nursing educator is reviewing the care of patients with feeding tubes and endotracheal tubes (ET). The educator has emphasized the need to check for tube placement in the stomach as well as residual volume. What is the main purpose of this nursing action? A) Prevent gastric ulcers B) Prevent aspiration C) Prevent abdominal distention D) Prevent diarrhea
B) Prevent aspiration
Protecting the client from aspirating is essential because aspiration can cause pneumonia, a potentially life-threatening disorder. Gastric ulcers are not a common complication of tube feeding in clients with ET tubes. Abdominal distention and diarrhea can both be associated with tube feeding, but prevention of these problems is not the primary rationale for confirming placement.
The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurses assessments most directly addresses a major complication of TPN?
a. Checking the patients capillary blood glucose levels regularly
b. Having the patient frequently rate his or her hunger on a 10-point scale
c. Measuring the patients heart rhythm at least every 6 hours
d. Monitoring the patients level of consciousness each shift
a. Checking the patients capillary blood glucose levels regularly
The solution, used as a base for most TPN, consists of a high dextrose concentration and may raise blood glucose levels significantly, resulting in hyperglycemia. This is a more salient threat than hunger, though this should be addressed. Dysrhythmias and decreased LOC are not among the most common complications.
A critical care nurse is caring for a patient diagnosed with acute pancreatitis. The nurse knows that the indications for starting parenteral nutrition (PN) for this patient are what?
a. 5% deficit in body weight compared to preillness weight and increased caloric need
b. Calorie deficit and muscle wasting combined with low electrolyte levels
c. Inability to take in adequate oral food or fluids within 7 days
d. Significant risk of aspiration coupled with decreased level of consciousness
c. Inability to take in adequate oral food or fluids within 7 days
The indications for PN include an inability to ingest adequate oral food or fluids within 7 days. Weight loss, muscle wasting combined with electrolyte imbalances, and aspiration indicate a need for nutritional support, but this does not necessary have to be parenteral.
A nurse is preparing to administer a patients intravenous fat emulsion simultaneously with parenteral nutrition (PN). Which of the following principles should guide the nurses action?
A) Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered.
B) The nurse should prepare for placement of another intravenous line, as intravenous fat emulsions may not be infused simultaneously through the line used for PN.
C) Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site after running the emulsion through a filter.
D) The intravenous fat emulsions can be piggy-backed into any existing IV solution that is infusing.
A) Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered.
Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. The patient does not need another intravenous line for the fat emulsion. The IVFE cannot be piggy-backed into any existing IV solution that is infusing.
A nurse is participating in a patients care conference and the team is deciding between parenteral nutrition (PN) and a total nutritional admixture (TNA). What advantages are associated with providing TNA rather than PN?
A) TNA can be mixed by a certified registered nurse.
B) TNA can be administered over 8 hours, while PN requires 24-hour administration.
C) TNA is less costly than PN.
D) TNA does not require the use of a micron filter.
C) TNA is less costly than PN.
TNA is mixed in one container and administered to the patient over a 24-hour period. A 1.5-micron filter is used with the TNA solution. Advantages of the TNA over PN include cost savings. Pharmacy staff must prepare both solutions.
A nurse is initiating parenteral nutrition (PN) to a postoperative patient who has developed complications. The nurse should initiate therapy by performing which of the following actions?
A) Starting with a rapid infusion rate to meet the patients nutritional needs as quickly as possible
B) Initiating the infusion slowly and monitoring the patients fluid and glucose tolerance
C) Changing the rate of administration every 2 hours based on serum electrolyte values
D) Increasing the rate of infusion at mealtimes to mimic the circadian rhythm of the body
B) Initiating the infusion slowly and monitoring the patients fluid and glucose tolerance
PN solutions are initiated slowly and advanced gradually each day to the desired rate as the patients fluid and glucose tolerance permits. The formulation of the PN solutions is calculated carefully each day to meet the complete nutritional needs of the individual patient based on clinical findings and laboratory data. It is not infused more quickly at mealtimes.
A patients physician has determined that for the next 3 to 4 weeks the patient will require parenteral nutrition (PN). The nurse should anticipate the placement of what type of venous access device? A) Peripheral catheter B) Nontunneled central catheter C) Implantable port D) Tunneled central catheter
B) Nontunneled central catheter
Nontunneled central catheters are used for short-term (less than 6 weeks) IV therapy. A peripheral catheter can be used for the administration of peripheral parenteral nutrition for 5 to 7 days. Implantable ports and tunneled central catheters are for long-term use and may remain in place for many years. Peripherally inserted central catheters (PICCs) are another potential option.
A nurse is caring for a patient who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the patient?
A) Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN.
B) Administer a hypertonic dextrose solution for 1 to 2 hours after discontinuing the PN.
C) Administer 3 ampules of dextrose 50% immediately prior to discontinuing the PN.
D) Administer 3 ampules of dextrose 50% 1 hour after discontinuing the PN.
A) Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN.
After administration of the PN solution is gradually discontinued, an isotonic dextrose solution is administered for 1 to 2 hours to protect against rebound hypoglycemia. The other listed actions would likely cause hyperglycemia.
A nurse is caring for a patient with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this patient, what nursing diagnosis should the nurse prioritize?
A) Risk for Activity Intolerance Related to the Presence of a Subclavian Catheter
B) Risk for Infection Related to the Presence of a Subclavian Catheter
C) Risk for Functional Urinary Incontinence Related to the Presence of a Subclavian Catheter
D) Risk for Sleep Deprivation Related to the presence of a Subclavian Catheter
B) Risk for Infection Related to the Presence of a Subclavian Catheter
The high glucose content of PN solutions makes the solutions an idea culture media for bacterial and fungal growth, and the central venous access devices provide a port of entry. Prevention of infection is consequently a high priority. The patient will experience some inconveniences with regard to toileting, activity, and sleep, but the infection risk is a priority over each of these.
A patients health decline necessitates the use of total parenteral nutrition. The patient has questioned the need for insertion of a central venous catheter, expressing a preference for a normal IV. The nurse should know that peripheral administration of high-concentration PN formulas is contraindicated because of the risk for what complication? A) Chemical phlebitis B) Hyperglycemia C) Dumping syndrome D) Line sepsis
A) Chemical phlebitis
Formulations with dextrose concentrations of more than 10% should not be administered through peripheral veins because they irritate the intima (innermost walls) of small veins, causing chemical phlebitis. Hyperglycemia and line sepsis are risks with both peripheral and central administration of PN. PN is not associated with dumping syndrome.
A nurse is providing care for a patient with a diagnosis of late-stage Alzheimers disease. The patient has just returned to the medical unit to begin supplemental feedings through an NG tube. Which of the nurses assessments addresses this patients most significant potential complication of feeding?
A) Frequent assessment of the patients abdominal girth
B) Assessment for hemorrhage from the nasal insertion site
C) Frequent lung auscultation
D) Vigilant monitoring of the frequency and character of bowel movements
C) Frequent lung auscultation
Aspiration is a risk associated with tube feeding; this risk may be exacerbated by the patients cognitive deficits. Consequently, the nurse should auscultate the patients lungs and monitor oxygen saturation closely. Bowel function is important, but the risk for aspiration is a priority. Hemorrhage is highly unlikely and the patients abdominal girth is not a main focus of assessment.
The management of the patients gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly?
A) I clean my stoma twice a day with alcohol.
B) The only time I flush my tube is when Im putting in medications.
C) I flush my tube with water before and after each of my medications.
D) I try to stay still most of the time to avoid dislodging my tube.
C) I flush my tube with water before and after each of my medications.
Frequent flushing is needed to prevent occlusion, and should not just be limited to times of medication administration. Alcohol will irritate skin surrounding the insertion site and activity should be maintained as much as possible.
A nurse is caring for a patient with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The patients oxygen saturation is 89% by pulse oximetry. After ensuring the patients immediate safety, what is the nurses most appropriate action?
a. Perform chest physiotherapy.
b. Reduce the height of the patients bed and remove the NG tube.
c. Liaise with the dietitian to obtain a feeding solution with lower osmolarity.
d. Report possible signs of aspiration pneumonia to the primary care provider.
d. Report possible signs of aspiration pneumonia to the primary care provider.
The patient should be assessed for further signs of aspiration pneumonia. It is unnecessary to remove the NG tube and chest physiotherapy is not indicated. A different feeding solution will not resolve this complication.
A nurse is creating a care plan for a patient with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube?
A) Auscultate the patients abdomen after injecting air through the tube.
B) Assess the color and pH of aspirate.
C) Locate the marking made after the initial x-ray confirming placement.
D) Use a combination of at least two accepted methods for confirming placement.
D) Use a combination of at least two accepted methods for confirming placement.
There are a variety of methods to check tube placement. The safest way to confirm placement is to utilize a combination of assessment methods.
The nurse is assessing placement of a nasogastric tube that the patient has had in place for 2 days. The tube is draining green aspirate. What is the nurses most appropriate action?
A) Inform the physician that the tube may be in the patients pleural space.
B) Withdraw the tube 2 to 4 cm.
C) Leave the tube in its present position.
D) Advance the tube up to 8 cm.
C) Leave the tube in its present position.
The patients aspirate is from the gastric area when the nurse observes that the color of the aspirate is green. Further confirmation of placement is necessary, but there is likely no need for repositioning. Pleural secretions are pale yellow.
A patients new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patients care plan accordingly. What intervention should the nurse include in the patients plan of care?
A) Confirm placement of the tube prior to each medication administration.
B) Have the patient sip cool water to stimulate saliva production.
C) Keep the patient in a low Fowlers position when at rest.
D) Connect the tube to continuous wall suction when not in use.
A) Confirm placement of the tube prior to each medication administration.
Each time liquids or medications are administered, and once a shift for continuous feedings, the tube must be checked to ensure that it remains properly placed. If the NG tube is used for decompression, it is attached to intermittent low suction. During the placement of a nasogastric tube the patient should be positioned in a Fowlers position. Oral fluid administration is contraindicated by the patients dysphagia.
A patient has been brought to the emergency department by EMS after telling a family member that he deliberately took an overdose of NSAIDs a few minutes earlier. If lavage is ordered, the nurse should prepare to assist with the insertion of what type of tube? A) Nasogastric tube B) Levin tube C) Gastric sump D) Orogastric tube
D) Orogastric tube.
An orogastric tube is a large-bore tube inserted through the mouth with a wide outlet for removal of gastric contents; it is used primarily in the emergency department or an intensive care setting. Nasogastric, Levin, and gastric sump tubes are not used for this specific purpose.
A patients NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next?
a. Withdraw the NG tube 3 to 5 cm and reattempt aspiration.
b. Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.
c. Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers.
d. Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider.
b. Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.
When a tube is first noted to be clogged, a 30- to 60-mL syringe should be attached to the end of the tube and any contents aspirated and discarded. Then the syringe should be filled with warm water, attached to the tube again, and a back-and-forth motion initiated to help loosen the clog. Removal is not warranted at this early stage and a flicking motion is not recommended. The tube should not be withdrawn, even a few centimeters.
A nurse has obtained an order to remove a patients NG tube and has prepared the patient accordingly. After flushing the tube and removing the nasal tape, the nurse attempts removal but is met with resistance. Because the nurse is unable to overcome this resistance, what is the most appropriate action?
a. Gently twist the tube before pulling.
b. Instill a digestive enzyme solution and reattempt removal in 10 to 15 minutes.
c. Flush the tube with hot tap water and reattempt removal.
d. Report this finding to the patients primary care provider.
d. Report this finding to the patients primary care provider.
If the tube does not come out easily, force should not be used, and the problem should be reported to the primary provider. Enzymes are used to resolve obstructions, not to aid removal. For safety reasons, hot water is never instilled into a tube. Twisting could cause damage to the mucosa.
A nurse is writing a care plan for a patient with a nasogastric tube in place for gastric decompression. What risk nursing diagnosis is the most appropriate component of the care plan?
A) Risk for Excess Fluid Volume Related to Enteral Feedings
B) Risk for Impaired Skin Integrity Related to the Presence of NG Tube
C) Risk for Unstable Blood Glucose Related to Enteral Feedings
D) Risk for Impaired Verbal Communication Related to Presence of NG Tube
B) Risk for Impaired Skin Integrity Related to the Presence of NG Tube
NG tubes can easily damage the delicate mucosa of the nose, sinuses, and upper airway. An NG tube does not preclude verbal communication. This patients NG tube is in place for decompression, so complications of enteral feeding do not apply.
