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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.
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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.
A nurse has obtained an order to remove a patients NG tube and has prepared the patient accordingly. After flushing the tube and removing the nasal tape, the nurse attempts removal but is met with resistance. Because the nurse is unable to overcome this resistance, what is the most appropriate action?
- A. Gently twist the tube before pulling.
- B. Instill a digestive enzyme solution and reattempt removal in 10 to 15 minutes.
- C. Flush the tube with hot tap water and reattempt removal.
- D. Report this finding to the patients primary care provider.
Correct Answer: D
Rationale: If the tube does not come out easily, force should not be used, and the problem should be reported to the primary provider. Enzymes are used to resolve obstructions, not to aid removal. For safety reasons, hot water is never instilled into a tube. Twisting could cause damage to the mucosa.
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 critical care nurse is caring for a patient diagnosed with acute pancreatitis. The nurse knows that the indications for starting parenteral nutrition (PN) for this patient are what?
- A. 5% deficit in body weight compared to preillness weight and increased caloric need
- B. Calorie deficit and muscle wasting combined with low electrolyte levels
- C. Inability to take in adequate oral food or fluids within 7 days
- D. Significant risk of aspiration coupled with decreased level of consciousness
Correct Answer: C
Rationale: The indications for PN include an inability to ingest adequate oral food or fluids within 7 days. Weight loss, muscle wasting combined with electrolyte imbalances, and aspiration indicate a need for nutritional support, but this does not necessarily have to be parenteral.