Nokea
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
Correct Answer: C
Rationale: 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 necessarily have to be parenteral.
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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.
Correct Answer: A
Rationale: 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 nurse is caring for a patient who has a gastrointestinal tube in place. Which of the following are indications for gastrointestinal intubation? Select all that apply.
- A. To remove gas from the stomach
- B. To administer clotting factors to treat a GI bleed
- C. To remove toxins from the stomach
- D. To open sphincters that are closed
- E. To diagnose GI motility disorders
Correct Answer: A,C,E
Rationale: GI intubation may be performed to decompress the stomach and remove gas and fluid, lavage (flush with water or other fluids) the stomach and remove ingested toxins or other harmful materials, diagnose disorders of GI motility and other disorders, administer medications and feedings, compress a bleeding site, and aspirate gastric contents for analysis. GI intubation is not used for opening sphincters that are not functional or for administering clotting factors.
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.
Correct Answer: A
Rationale: 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 is postoperative day I following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate?
- A. Administer antibiotics via the tube as ordered.
- B. Wash the area around the tube with soap and water daily.
- C. Cleanse the skin within 2 cm of the insertion site with hydrogen peroxide once per shift.
- D. Irrigate the skin surrounding the insertion site with normal saline before each use.
Correct Answer: B
Rationale: Infection can be prevented by keeping the skin near the insertion site clean using soap and water. Hydrogen peroxide is not used, due to associated skin irritation. The skin around the site is not irrigated with normal saline and antibiotics are not administered to prevent site infection.
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.
Correct Answer: A
Rationale: 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.