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A patient has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurses priority during this aspect of the patients care?
- A. Measure and record drainage.
- B. Monitor drainage for change in color.
- C. Titrate the suction every hour.
- D. Feed the patient via the G tube as ordered.
Correct Answer: A
Rationale: This drainage should be measured and recorded because it is a significant indicator of GI function. The nurse should indeed monitor the color of the output, but fluid balance is normally the priority. Frequent titration of the suction should not be necessary and feeding is contraindicated if the G tube is in place for drainage.
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A patients NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next?
- A. Withdraw the NG tube 3 to 5 cm and reattempt aspiration.
- B. Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.
- C. Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers.
- D. Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider.
Correct Answer: B
Rationale: When a tube is first noted to be clogged, a 30- to 60-mL syringe should be attached to the end of the tube and any contents aspirated and discarded. Then the syringe should be filled with warm water, attached to the tube again, and a back-and-forth motion initiated to help loosen the clog. Removal is not warranted at this early stage and a flicking motion is not recommended. The tube should not be withdrawn, even a few centimeters.
A patient has been brought to the emergency department by EMS after telling a family member that he deliberately took an overdose of NSAIDs a few minutes earlier. If lavage is ordered, the nurse should prepare to assist with the insertion of what type of tube?
- A. Nasogastric tube
- B. Levin tube
- C. Gastric sump
- D. Orogastric tube
Correct Answer: D
Rationale: An orogastric tube is a large-bore tube inserted through the mouth with a wide outlet for removal of gastric contents; it is used primarily in the emergency department or an intensive care setting. Nasogastric, Levin, and gastric sump tubes are not used for this specific purpose.
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.
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.
A nurse is creating a care plan for a patient with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube?
- A. Auscultate the patients abdomen after injecting air through the tube.
- B. Assess the color and pH of aspirate.
- C. Locate the marking made after the initial x-ray confirming placement.
- D. Use a combination of at least two accepted methods for confirming placement.
Correct Answer: D
Rationale: There are a variety of methods to check tube placement. The safest way to confirm placement is to utilize a combination of assessment methods.