Nokea
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.
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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 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)
Correct Answer: A
Rationale: 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 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
Correct Answer: C
Rationale: 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.
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.
You are caring for a patient who was admitted to have a low-profile gastrostomy device (LPGD) placed. How soon after the original gastrostomy tube placement can an LPGD be placed?
- A. 2 weeks
- B. 4 to 6 weeks
- C. 2 to 3 months
- D. 4 to 6 months
Correct Answer: C
Rationale: An alternative to the PEG device is a low-profile gastrostomy device (LPGD). LPGDs may be inserted 2 to 3 months after initial gastrostomy tube placement.