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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.
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A patient who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The patient has since become comatose and the patients family asks the nurse why the physician is recommending the removal of the patients NG tube and the insertion of a gastrostomy tube. What is the nurses best response?
- A. It eliminates the risk for infection.
- B. Feeds can be infused at a faster rate.
- C. Regurgitation and aspiration are less likely.
- D. It allows caregivers to provide personal hygiene more easily.
Correct Answer: C
Rationale: Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG feedings. Both tubes carry a risk for infection; this change in care is not motivated by the possibility of faster infusion or easier personal care.
Prior to a patients scheduled jejunostomy, the nurse is performing the preoperative assessment. What goal should the nurse prioritize during the preoperative assessment?
- A. Determining the patients nutritional needs
- B. Determining that the patient fully understands the postoperative care required
- C. Determining the patients ability to understand and cooperate with the procedure
- D. Determining the patients ability to cope with an altered body image
Correct Answer: C
Rationale: The major focus of the preoperative assessment is to determine the patients ability both to understand and cooperate with the procedure. Body image, nutritional needs, and postoperative care are all important variables, but they are not the main focuses of assessment during the immediate preoperative period.
A nurse is preparing to place a patients ordered nasogastric tube. How should the nurse best determine the correct length of the nasogastric tube?
- A. Place distal tip to nose, then ear tip and end of xiphoid process.
- B. Instruct the patient to lie prone and measure tip of nose to umbilical area.
- C. Insert the tube into the patients nose until secretions can be aspirated.
- D. Obtain an order from the physician for the length of tube to insert.
Correct Answer: A
Rationale: Tube length is traditionally determined by (1) measuring the distance from the tip of the nose to the earlobe and from the earlobe to the xiphoid process, and (2) adding up to 6 inches for NG placement or at least 8 to 10 inches or more for intestinal placement, although studies do not necessarily confirm that this is a reliable technique. The physician would not prescribe a specific length and the umbilicus is not a landmark for this process. Length is not determined by aspirating from the tube.
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 patient is postoperative day I following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate?
- A. Administer antibiotics via the tube as ordered.
- B. Wash the area around the tube with soap and water daily.
- C. Cleanse the skin within 2 cm of the insertion site with hydrogen peroxide once per shift.
- D. Irrigate the skin surrounding the insertion site with normal saline before each use.
Correct Answer: B
Rationale: Infection can be prevented by keeping the skin near the insertion site clean using soap and water. Hydrogen peroxide is not used, due to associated skin irritation. The skin around the site is not irrigated with normal saline and antibiotics are not administered to prevent site infection.