Nokea
A nurse is caring for a patient who is receiving parenteral nutrition. When writing this patients plan of care, which of the following nursing diagnoses should be included?
- A. Risk for Peripheral Neurovascular Dysfunction Related to Catheter Placement
- B. Ineffective Role Performance Related to Parenteral Nutrition
- C. Bowel Incontinence Related to Parenteral Nutrition
- D. Chronic Pain Related to Catheter Placement
Correct Answer: B
Rationale: The limitations associated with PN can make it difficult for patients to maintain their usual roles. PN does not normally cause bowel incontinence and catheters are not associated with chronic pain or neurovascular dysfunction.
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A patient who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The patient has since become comatose and the patients family asks the nurse why the physician is recommending the removal of the patients NG tube and the insertion of a gastrostomy tube. What is the nurses best response?
- A. It eliminates the risk for infection.
- B. Feeds can be infused at a faster rate.
- C. Regurgitation and aspiration are less likely.
- D. It allows caregivers to provide personal hygiene more easily.
Correct Answer: C
Rationale: Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG feedings. Both tubes carry a risk for infection; this change in care is not motivated by the possibility of faster infusion or easier personal care.
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.
Correct Answer: B
Rationale: 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 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.
Correct Answer: D
Rationale: 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.
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.
Correct Answer: C
Rationale: 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 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
Correct Answer: B
Rationale: 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.