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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.
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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 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.
A patient receiving tube feedings is experiencing diarrhea. The nurse and the physician suspect that the patient is experiencing dumping syndrome. What intervention is most appropriate?
- A. Stop the tube feed and aspirate stomach contents.
- B. Increase the hourly feed rate so it finishes earlier.
- C. Dilute the concentration of the feeding solution.
- D. Administer fluid replacement by IV.
Correct Answer: C
Rationale: Dumping syndrome can generally be alleviated by starting with a dilute solution and then increasing the concentration of the solution over several days. Fluid replacement may be necessary but does not prevent or treat dumping syndrome. There is no need to aspirate stomach contents. Increasing the rate will exacerbate the problem.
The nurse is preparing to insert a patients ordered NG tube. What factor should the nurse recognize as a risk for incorrect placement?
- A. The patient is obese and has a short neck.
- B. The patient is agitated.
- C. The patient has a history of gastroesophageal reflux disease (GERD).
- D. The patient is being treated for pneumonia.
Correct Answer: B
Rationale: Inappropriate placement may occur in patients with decreased levels of consciousness, confused mental states, poor or absent cough and gag reflexes, or agitation during insertion. A short neck, GERD, and pneumonia are not linked to incorrect placement.
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.