Nokea
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.
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A nurse is preparing to discharge a patient home on parenteral nutrition. What should an effective home care teaching program address? Select all that apply.
- A. Preparing the patient to troubleshoot for problems
- B. Teaching the patient and family strict aseptic technique
- C. Teaching the patient and family how to set up the infusion
- D. Teaching the patient to flush the line with sterile water
- E. Teaching the patient when it is safe to leave the access site open to air
Correct Answer: A,B,C
Rationale: An effective home care teaching program prepares the patient to store solutions, set up the infusion, flush the line with heparin, change the dressings, and troubleshoot for problems. The most common complication is sepsis. Strict aseptic technique is taught for hand hygiene, handling equipment, changing the dressing, and preparing the solution. Sterile water is never used for flushes and the access site must never be left open to air.
A patients health decline necessitates the use of total parenteral nutrition. The patient has questioned the need for insertion of a central venous catheter, expressing a preference for a normal IV. The nurse should know that peripheral administration of high-concentration PN formulas is contraindicated because of the risk for what complication?
- A. Chemical phlebitis
- B. Hyperglycemia
- C. Dumping syndrome
- D. Line sepsis
Correct Answer: A
Rationale: Formulations with dextrose concentrations of more than 10% should not be administered through peripheral veins because they irritate the intima (innermost walls) of small veins, causing chemical phlebitis. Hyperglycemia and line sepsis are risks with both peripheral and central administration of PN. PN is not associated with dumping syndrome.
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.
The nurse is assessing placement of a nasogastric tube that the patient has had in place for 2 days. The tube is draining green aspirate. What is the nurses most appropriate action?
- A. Inform the physician that the tube may be in the patients pleural space.
- B. Withdraw the tube 2 to 4 cm.
- C. Leave the tube in its present position.
- D. Advance the tube up to 8 cm.
Correct Answer: C
Rationale: The patients aspirate is from the gastric area when the nurse observes that the color of the aspirate is green. Further confirmation of placement is necessary, but there is likely no need for repositioning. Pleural secretions are pale yellow.
A patients enteral feedings have been determined to be too concentrated based on the patients development of dumping syndrome. What physiologic phenomenon caused this patients complication of enteral feeding?
- A. Increased gastric secretion of HCl and gastrin because of high osmolality of feeds
- B. Entry of large amounts of water into the small intestine because of osmotic pressure
- C. Mucosal irritation of the stomach and small intestine by the high concentration of the feed
- D. Acid-base imbalance resulting from the high volume of solutes in the feed
Correct Answer: B
Rationale: When a concentrated solution of high osmolality entering the intestines is taken in quickly or in large amounts, water moves rapidly into the intestinal lumen from fluid surrounding the organs and the vascular compartment. This results in dumping syndrome. Dumping syndrome is not the result of changes in HCl or gastrin levels. It is not caused by an acid-base imbalance or direct irritation of the GI mucosa.