Nokea
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.
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A nurse is caring for a patient who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the patient?
- A. Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN.
- B. Administer a hypertonic dextrose solution for 1 to 2 hours after discontinuing the PN.
- C. Administer 3 ampules of dextrose 50% immediately prior to discontinuing the PN.
- D. Administer 3 ampules of dextrose 50% 1 hour after discontinuing the PN.
Correct Answer: A
Rationale: After administration of the PN solution is gradually discontinued, an isotonic dextrose solution is administered for 1 to 2 hours to protect against rebound hypoglycemia. The other listed actions would likely cause hyperglycemia.
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.
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 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.
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.