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A nurse is providing care for a client with a diagnosis of late-stage Alzheimer disease.
The client has just returned to the medical unit to begin supplemental feedings through
an NG tube. Which of the nurse's assessments addresses this client's most significant
potential complication of feeding?
A) Frequent assessment of the client's abdominal girth
B) Assessment for hemorrhage from the nasal insertion site
C) Frequent lung auscultation
D) Vigilant monitoring of the frequency and character of bowel movements -
ANSWERS-C) Frequent lung auscultation
The nurse is caring for a client who has a nasogastric tube that has been in place for 2
days. Before administering a scheduled feeding, the nurse should
A) ensure that the client has recently voided.
B) administer 30 to 45 mL of water to confirm placement.
C) position the client upright.
D) perform a focused gastrointestinal assessment. - ANSWERS-C) position the client
upright
, A nurse is admitting a client 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) - ANSWERS-A) Premature removal of
the G tube
A client's enteral feedings have been determined to be too concentrated based on the
client's development of dumping syndrome. What physiologic phenomenon caused this
client's complication of enteral feeding?
A) Increased gastric secretion of HCl and gastrin because of high osmolality of feeds.
B) Entry of large amounts of water into the small intestine because of osmotic pressure
C) Mucosal irritation of the stomach and small intestine by the high concentration of the
feed
D) Acid-base imbalance resulting from the high volume of solutes in the feed -
ANSWERS-B) Entry of large amounts of water into the small intestine because of
osmotic pressure
A client with dysphagia is scheduled for percutaneous endoscopic gastrostomy (PEG)
tube insertion and asks the nurse how the tube will stay in place. What is the nurse's
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) Internal and external fixation bolsters secure the tube against the stomach wall. -
ANSWERS-D) Internal and external fixation bolsters secure the tube against the
stomach wall.