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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.
Correct Answer: D
Rationale: 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.
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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.
A nurse is preparing to administer a patients scheduled parenteral nutrition (PN). Upon inspecting the bag, the nurse notices that the presence of small amounts of white precipitate are present in the bag. What is the nurses best action?
- A. Recognize this as an expected outcome.
- B. Place the bag in a warm environment for 30 minutes.
- C. Shake the bag vigorously for 10 to 20 seconds.
- D. Contact the pharmacy to obtain a new bag of PN.
Correct Answer: D
Rationale: Before PN infusion is administered, the solution must be inspected for separation, oily appearance (also known as a cracked solution), or any precipitate (which appears as white crystals). If any of these are present, it is not safe to use. Warming or shaking the bag is inappropriate and unsafe.
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
Correct Answer: B
Rationale: 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 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
Correct Answer: B
Rationale: The high glucose content of PN solutions makes the solutions an ideal 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 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.