Nokea
The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurses assessments most directly addresses a major complication of TPN?
- A. Checking the patients capillary blood glucose levels regularly
- B. Having the patient frequently rate his or her hunger on a 10-point scale
- C. Measuring the patients heart rhythm at least every 6 hours
- D. Monitoring the patients level of consciousness each shift
Correct Answer: A
Rationale: The solution, used as a base for most TPN, consists of a high dextrose concentration and may raise blood glucose levels significantly, resulting in hyperglycemia. This is a more salient threat than hunger, though this should be addressed. Dysrhythmias and decreased LOC are not among the most common complications.
You may also like to solve these questions
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 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 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.
A nurse is admitting a patient to the postsurgical unit following a gastrostomy. When planning assessments, the nurse should be aware of what potential postoperative complication of a gastrostomy?
- A. Premature removal of the G tube
- B. Bowel perforation
- C. Constipation
- D. Development of peptic ulcer disease (PUD)
Correct Answer: A
Rationale: A significant postoperative complication of a gastrostomy is premature removal of the G tube. Constipation is a less immediate threat and bowel perforation and PUD are not noted to be likely complications.
A nurse is writing a care plan for a patient with a nasogastric tube in place for gastric decompression. What risk nursing diagnosis is the most appropriate component of the care plan?
- A. Risk for Excess Fluid Volume Related to Enteral Feedings
- B. Risk for Impaired Skin Integrity Related to the Presence of NG Tube
- C. Risk for Unstable Blood Glucose Related to Enteral Feedings
- D. Risk for Impaired Verbal Communication Related to Presence of NG Tube
Correct Answer: B
Rationale: NG tubes can easily damage the delicate mucosa of the nose, sinuses, and upper airway. An NG tube does not preclude verbal communication. This patients NG tube is in place for decompression, so complications of enteral feeding do not apply.