Chapter 44- GI Questions And Answers
A nurse is preparing to place a patient's ordered nasogastric tube. How should the
nurse best determine the correct length of the nasogastric tube?
A)
Place distal tip to nose, then ear tip and end of xiphoid process.
B)
Instruct the patient to lie prone and measure tip of nose to umbilical area.
C)
Insert the tube into the patient's nose until secretions can be aspirated.
D)
Obtain an order from the physician for the length of tube to insert. - Answer - A
Feedback:
Tube length is traditionally determined by (1) measuring the distance from the tip of the
nose to the earlobe and from the earlobe to the xiphoid process, and (2) adding up to 6
inches for NG placement or at least 8 to 10 inches or more for intestinal placement,
although studies do not necessarily confirm that this is a reliable technique. The
physician would not prescribe a specific length and the umbilicus is not a landmark for
this process. Length is not determined by aspirating from the tube.
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 patient's waist.
C)
Maintain the patient in a high Fowler's position.
D)
Have the patient pin the tube to the thigh. - Answer - B
Feedback:
The blue vent lumen should be kept above the patient's 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 Fowler's
position, or have the patient pin the tube to the thigh.
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 - Answer - C
Feedback:
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.
A nurse is admitting a patient 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) - Answer - A
Feedback:
A significant postoperative complication of a gastrostomy is premature removal of the G
tube. Constipation is a less immediate threat and bowel perforation and PUD are not
noted to be likely complications.
A nursing educator is reviewing the care of patients with feeding tubes and
endotracheal tubes (ET). The educator has emphasized the need to check for tube
placement in the stomach as well as residual volume. What is the main purpose of this
nursing action?
A)
Prevent gastric ulcers
B)
Prevent aspiration
C)
Prevent abdominal distention
D)
Prevent diarrhea - Answer - B
, Feedback:
Protecting the client from aspirating is essential because aspiration can cause
pneumonia, a potentially life-threatening disorder. Gastric ulcers are not a common
complication of tube feeding in clients with ET tubes. Abdominal distention and diarrhea
can both be associated with tube feeding, but prevention of these problems is not the
primary rationale for confirming placement.
The nurse is administering total parenteral nutrition (TPN) to a client who underwent
surgery for gastric cancer. Which of the nurse's assessments most directly addresses a
major complication of TPN?
A)
Checking the patient's capillary blood glucose levels regularly
B)
Having the patient frequently rate his or her hunger on a 10-point scale
C)
Measuring the patient's heart rhythm at least every 6 hours
D)
Monitoring the patient's level of consciousness each shift - Answer - A
Feedback:
The solution, used as a base for most TPN, consists of a high dextrose concentration
and may raise blood glucose levels significantly, resulting in hyperglycemia. This is a
more salient threat than hunger, though this should be addressed. Dysrhythmias and
decreased LOC are not among the most common complications.
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 - Answer -
C
Feedback:
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 necessary have to be
parenteral.
A nurse is preparing to place a patient's ordered nasogastric tube. How should the
nurse best determine the correct length of the nasogastric tube?
A)
Place distal tip to nose, then ear tip and end of xiphoid process.
B)
Instruct the patient to lie prone and measure tip of nose to umbilical area.
C)
Insert the tube into the patient's nose until secretions can be aspirated.
D)
Obtain an order from the physician for the length of tube to insert. - Answer - A
Feedback:
Tube length is traditionally determined by (1) measuring the distance from the tip of the
nose to the earlobe and from the earlobe to the xiphoid process, and (2) adding up to 6
inches for NG placement or at least 8 to 10 inches or more for intestinal placement,
although studies do not necessarily confirm that this is a reliable technique. The
physician would not prescribe a specific length and the umbilicus is not a landmark for
this process. Length is not determined by aspirating from the tube.
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 patient's waist.
C)
Maintain the patient in a high Fowler's position.
D)
Have the patient pin the tube to the thigh. - Answer - B
Feedback:
The blue vent lumen should be kept above the patient's 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 Fowler's
position, or have the patient pin the tube to the thigh.
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 - Answer - C
Feedback:
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.
A nurse is admitting a patient 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) - Answer - A
Feedback:
A significant postoperative complication of a gastrostomy is premature removal of the G
tube. Constipation is a less immediate threat and bowel perforation and PUD are not
noted to be likely complications.
A nursing educator is reviewing the care of patients with feeding tubes and
endotracheal tubes (ET). The educator has emphasized the need to check for tube
placement in the stomach as well as residual volume. What is the main purpose of this
nursing action?
A)
Prevent gastric ulcers
B)
Prevent aspiration
C)
Prevent abdominal distention
D)
Prevent diarrhea - Answer - B
, Feedback:
Protecting the client from aspirating is essential because aspiration can cause
pneumonia, a potentially life-threatening disorder. Gastric ulcers are not a common
complication of tube feeding in clients with ET tubes. Abdominal distention and diarrhea
can both be associated with tube feeding, but prevention of these problems is not the
primary rationale for confirming placement.
The nurse is administering total parenteral nutrition (TPN) to a client who underwent
surgery for gastric cancer. Which of the nurse's assessments most directly addresses a
major complication of TPN?
A)
Checking the patient's capillary blood glucose levels regularly
B)
Having the patient frequently rate his or her hunger on a 10-point scale
C)
Measuring the patient's heart rhythm at least every 6 hours
D)
Monitoring the patient's level of consciousness each shift - Answer - A
Feedback:
The solution, used as a base for most TPN, consists of a high dextrose concentration
and may raise blood glucose levels significantly, resulting in hyperglycemia. This is a
more salient threat than hunger, though this should be addressed. Dysrhythmias and
decreased LOC are not among the most common complications.
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 - Answer -
C
Feedback:
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 necessary have to be
parenteral.
