Nokea
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.
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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.
A patient with dysphagia is scheduled for PEG tube insertion and asks the nurse how the tube will stay in place. What is the nurses best response?
- A. Adhesive holds a flange in place against the abdominal skin.
- B. A stitch holds the tube in place externally.
- C. The tube is stitched to the abdominal skin externally and the stomach wall internally.
- D. An internal retention disc secures the tube against the stomach wall.
Correct Answer: D
Rationale: A PEG tube is held in place by an internal retention disc (flange) that holds it against the stomach wall. It is not held in place by stitches or adhesives.
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.
The nurse is caring for a patient who is postoperative from having a gastrostomy tube placed. What should the nurse do on a daily basis to prevent skin breakdown?
- A. Verify tube placement.
- B. Loop adhesive tape around the tube and connect it securely to the abdomen.
- C. Gently rotate the tube.
- D. Change the wet-to-dry dressing.
Correct Answer: C
Rationale: The nurse verifies the tubes placement and gently rotates the tube once daily to prevent skin breakdown. Verifying tube placement and taping the tube to the abdomen do not prevent skin breakdown. A gastrostomy wound does not have a wet-to-dry dressing.
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.
Correct Answer: A
Rationale: 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.