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Med Surge Exam 2
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Med/Surg Exam 2 Med Surg. Chapter 46 Management ... Pancreatitis test bank Psychia
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A client who underwent abdominal surgery and has a Assess patency of the NG tube.
nasogastric (NG) tube in place begins to complain of
abdominal pain that he describes as "feeling full and When an NG tube is no longer patent, stomach contents collect in the stomach,
uncomfortable." Which assessment should the nurse giving the client a sensation of fullness. The nurse should begin by assessing
perform first? patency of the NG tube. The nurse can measure abdominal girth, auscultate
bowels, and assess vital signs, but she should check NG tube patency first to help
relieve the client's discomfort.
Tube feedings are given to a patient after an oral surgery. Place patient in semi-Fowler's position during and 60 minutes after an intermittent
The nurse manages tube feedings to minimize the risk of feeding
aspiration. Which of the following measures should the
nurse include in the care plan to reduce the risk of To minimize the risk of aspiration, it is important to place the patient in a semi-
aspiration? Fowler's position during and 60 minutes after an intermittent feeding because
proper positioning prevents regurgitation. Checking tube placement and gastric
residual prior to feedings is another important measure because it prevents
improper infusion and vomiting. If aspiration is suspected, feeding should be
stopped as cessation prevents further problems and allows for treatment of the
immediate problem. Changing tube feeding container and tubing, monitoring
weight daily, and administering 15 to 30 mL of water before and after medications
and feedings are measures to maintain tube function.
Which of the following venous access devices can be Non tunneled catheter
used for less than 6 weeks in patients requiring parenteral
nutrition? The subclavian vein is the most common vessel used because the subclavian area
provides a stable insertion site to which the catheter can be anchored, and it
allows the patient freedom of movement, and provides easy access to the
dressing site. PICC lines may be used for intermediate terms (3 to 12 months).
Tunneled central catheters are for long-term use and may remain in place for
many years. Implanted ports are devices also used for long-term home IV therapy
(eg, Port-A-Cath, Mediport, Hickman Port, P.A.S. Port).
, Which of the following medications requires the nurse to Enteric-coated tablets
contact the pharmacist in consultation when the patient
receives all oral medications by feeding tube? Enteric-coated tablets are meant to be digested in the intestinal tract and may be
destroyed by stomach acids. A change in the form of medication is necessary for
patients with tube feedings. Simple compressed tablets may be crushed and
dissolved in water for patients receiving oral medications by feeding tube. Buccal
or sublingual tablets are absorbed by mucous membranes and may be given as
intended to the patient undergoing tube feedings. The nurse may make an
opening in the capsule and squeeze out contents for administration by feeding
tube.
The patient is on a continuous tube feeding. The tube Shift
placement should be checked every
Each nurse caring for the patient is responsible for verifying that the tube is
located in the proper area for continuous feeding. Checking for placement each
hour is unnecessary unless the patient is extremely restless or there is basis for
rechecking the tube based on other patient activities. Checking for placement
every 12 or 24 hours does not meet the standard of care due the patient receiving
continuous tube feedings.
The nurse inserts a nasoduodenal tube for feeding of the Verifies location with an abdominal x-ray
client. To check best for placement, the nurse
Initially, an x-ray should be used to confirm placement of the nasoduodenal tube.
It is the most accurate method to verify tube placement. Adding 8 to 10 inches to
the length of the tube after measuring from nose to earlobe to xiphoid process is
not supported, because it does not indicate that the tube will be in the correct
position. Intestinal aspirate is usually clear and yellow to bile-colored. Gastric
aspirate is usually cloudy and green, tan, off-white, or brown. Food particles may
be present. The traditional method of injecting air through the tube while
auscultating the epigastric area with a stethoscope to detect air insufflation is also
an unreliable indicator.
The nurse is to discontinue a nasogastric tube that had Flush with 10 mL of water.
been used for decompression. The first thing the nurse
does is Before a nasogastric tube is removed, the nurse flushes the tube with 10 mL of
water or normal saline to ensure that the tube is free of debris and away from the
gastric tissue. The tape keeps the tube in the correct position while flushing is
occurring and is then removed from the nose. The nurse then withdraws the tube
gently for 6 to 8 inches until the tip reaches the esophagus, and then the
remainder of the tube is withdrawn rapidly from the nostril. After the tube is
removed, the nurse provides oral hygiene.
A nurse administered a full strength feeding with an Consults with the physician about decreasing the feeding to half-strength
increased osmolality through a jejunostomy tube to a
client. Immediately following the feeding, the client The osmolality of normal body fluids is 300 mOsm/kg. A feeding with a higher
expelled a large amount of liquid brown stool and osmolality may cause dumping syndrome. The client may report a feeling of
exhibited a blood pressure of 86/58 and pulse rate of 112 fullness, nausea, or both and may exhibit diarrhea, hypotension, and tachycardia.
beats/min. The nurse The nurse needs to take steps to prevent dumping syndrome. Increasing the
amount of the feeding, administering the feeding at an extreme temperature, or
increasing the osmolality of the feedings will continue dumping syndrome. The
nurse needs to decrease the osmolality of the feeding as in administering a half-
strength solution.
Med Surge Exam 2
Save
Students also studied
Med/Surg Exam 2 Med Surg. Chapter 46 Management ... Pancreatitis test bank Psychia
Teacher 43 terms 64 terms 29 terms 558 term
tisoeur Preview tanyue Preview erineregister Preview twe
A client who underwent abdominal surgery and has a Assess patency of the NG tube.
nasogastric (NG) tube in place begins to complain of
abdominal pain that he describes as "feeling full and When an NG tube is no longer patent, stomach contents collect in the stomach,
uncomfortable." Which assessment should the nurse giving the client a sensation of fullness. The nurse should begin by assessing
perform first? patency of the NG tube. The nurse can measure abdominal girth, auscultate
bowels, and assess vital signs, but she should check NG tube patency first to help
relieve the client's discomfort.
Tube feedings are given to a patient after an oral surgery. Place patient in semi-Fowler's position during and 60 minutes after an intermittent
The nurse manages tube feedings to minimize the risk of feeding
aspiration. Which of the following measures should the
nurse include in the care plan to reduce the risk of To minimize the risk of aspiration, it is important to place the patient in a semi-
aspiration? Fowler's position during and 60 minutes after an intermittent feeding because
proper positioning prevents regurgitation. Checking tube placement and gastric
residual prior to feedings is another important measure because it prevents
improper infusion and vomiting. If aspiration is suspected, feeding should be
stopped as cessation prevents further problems and allows for treatment of the
immediate problem. Changing tube feeding container and tubing, monitoring
weight daily, and administering 15 to 30 mL of water before and after medications
and feedings are measures to maintain tube function.
Which of the following venous access devices can be Non tunneled catheter
used for less than 6 weeks in patients requiring parenteral
nutrition? The subclavian vein is the most common vessel used because the subclavian area
provides a stable insertion site to which the catheter can be anchored, and it
allows the patient freedom of movement, and provides easy access to the
dressing site. PICC lines may be used for intermediate terms (3 to 12 months).
Tunneled central catheters are for long-term use and may remain in place for
many years. Implanted ports are devices also used for long-term home IV therapy
(eg, Port-A-Cath, Mediport, Hickman Port, P.A.S. Port).
, Which of the following medications requires the nurse to Enteric-coated tablets
contact the pharmacist in consultation when the patient
receives all oral medications by feeding tube? Enteric-coated tablets are meant to be digested in the intestinal tract and may be
destroyed by stomach acids. A change in the form of medication is necessary for
patients with tube feedings. Simple compressed tablets may be crushed and
dissolved in water for patients receiving oral medications by feeding tube. Buccal
or sublingual tablets are absorbed by mucous membranes and may be given as
intended to the patient undergoing tube feedings. The nurse may make an
opening in the capsule and squeeze out contents for administration by feeding
tube.
The patient is on a continuous tube feeding. The tube Shift
placement should be checked every
Each nurse caring for the patient is responsible for verifying that the tube is
located in the proper area for continuous feeding. Checking for placement each
hour is unnecessary unless the patient is extremely restless or there is basis for
rechecking the tube based on other patient activities. Checking for placement
every 12 or 24 hours does not meet the standard of care due the patient receiving
continuous tube feedings.
The nurse inserts a nasoduodenal tube for feeding of the Verifies location with an abdominal x-ray
client. To check best for placement, the nurse
Initially, an x-ray should be used to confirm placement of the nasoduodenal tube.
It is the most accurate method to verify tube placement. Adding 8 to 10 inches to
the length of the tube after measuring from nose to earlobe to xiphoid process is
not supported, because it does not indicate that the tube will be in the correct
position. Intestinal aspirate is usually clear and yellow to bile-colored. Gastric
aspirate is usually cloudy and green, tan, off-white, or brown. Food particles may
be present. The traditional method of injecting air through the tube while
auscultating the epigastric area with a stethoscope to detect air insufflation is also
an unreliable indicator.
The nurse is to discontinue a nasogastric tube that had Flush with 10 mL of water.
been used for decompression. The first thing the nurse
does is Before a nasogastric tube is removed, the nurse flushes the tube with 10 mL of
water or normal saline to ensure that the tube is free of debris and away from the
gastric tissue. The tape keeps the tube in the correct position while flushing is
occurring and is then removed from the nose. The nurse then withdraws the tube
gently for 6 to 8 inches until the tip reaches the esophagus, and then the
remainder of the tube is withdrawn rapidly from the nostril. After the tube is
removed, the nurse provides oral hygiene.
A nurse administered a full strength feeding with an Consults with the physician about decreasing the feeding to half-strength
increased osmolality through a jejunostomy tube to a
client. Immediately following the feeding, the client The osmolality of normal body fluids is 300 mOsm/kg. A feeding with a higher
expelled a large amount of liquid brown stool and osmolality may cause dumping syndrome. The client may report a feeling of
exhibited a blood pressure of 86/58 and pulse rate of 112 fullness, nausea, or both and may exhibit diarrhea, hypotension, and tachycardia.
beats/min. The nurse The nurse needs to take steps to prevent dumping syndrome. Increasing the
amount of the feeding, administering the feeding at an extreme temperature, or
increasing the osmolality of the feedings will continue dumping syndrome. The
nurse needs to decrease the osmolality of the feeding as in administering a half-
strength solution.
