Nokea
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.
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A nurse is caring for a patient with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The patients oxygen saturation is 89% by pulse oximetry. After ensuring the patients immediate safety, what is the nurses most appropriate action?
- A. Perform chest physiotherapy.
- B. Reduce the height of the patients bed and remove the NG tube.
- C. Liaise with the dietitian to obtain a feeding solution with lower osmolarity.
- D. Report possible signs of aspiration pneumonia to the primary care provider.
Correct Answer: D
Rationale: The patient should be assessed for further signs of aspiration pneumonia. It is unnecessary to remove the NG tube and chest physiotherapy is not indicated. A different feeding solution will not resolve this complication.
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 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.
A nurse is initiating parenteral nutrition (PN) to a postoperative patient who has developed complications. The nurse should initiate therapy by performing which of the following actions?
- A. Starting with a rapid infusion rate to meet the patients nutritional needs as quickly as possible
- B. Initiating the infusion slowly and monitoring the patients fluid and glucose tolerance
- C. Changing the rate of administration every 2 hours based on serum electrolyte values
- D. Increasing the rate of infusion at mealtimes to mimic the circadian rhythm of the body
Correct Answer: B
Rationale: PN solutions are initiated slowly and advanced gradually each day to the desired rate as the patients fluid and glucose tolerance permits. The formulation of the PN solutions is calculated carefully each day to meet the complete nutritional needs of the individual patient based on clinical findings and laboratory data. It is not infused more quickly at mealtimes.