Adult Health: Complex Exam 3; 2022/2023 with Complete Solutions
___ is used when the patient is unable to take in nutritional support orally; administration of
nutritionally balanced and liquified foods {{Ans- enteral tube feeding
___ will be inserted stomach, jejunum, duodenum {{Ans- enteral tube
Clients receiving an enteral tube feeding MUST have ___ {{Ans- a functioning GI tract
When patients are receiving tube feedings, the head of the bed should be elevated to at least ___-___
degrees {{Ans- 30-45
Tube patency must be assessed at least every ___ and/or before and after tube is used for a feeding
{{Ans- 4 hours
Assess ___, ___, ___, ___, ___, ___, ___ every 4 hours, even if patient is on continuous feeds
{{Ans-
- shape & feel of abdomen
- bowel sound presences (all quadrants)
- tenderness upon palpation
- stability of tube (look at marker outside tube)
- daily weights
- accurate I&O
- glucose checks for first 24 hours
pH ___ indicates that the tube is in the stomach (gastrostomy tube) {{Ans- <4
pH ___ indicates the tube is in the jejunum (jejunostomy tube) {{Ans- >6
3 complications of enteral feedings
{{Ans-
- overfeeding (nausea, vomiting, abdominal distention)
- diarrhea/dumping syndrome
- aspiration pneumonia
Assess residuals every ___-___ {{Ans- 4-6 hours
6 nursing actions to treat complications of enteral tube feedings
{{Ans-
- stop feeding
- suction airway while patient is laying on side
- provide oxygen
,- watch for increase in temp. (infection)
- auscultate breath sounds
- chest x-ray
___ is intravenous administration of amino acids, with carbohydrates, fats, electrolytes, vitamins,
minerals; must be administered through a central vein or PICC lines
{{Ans- parenteral tube feedings (TPN)
TPN is usually given IV as a ___ {{Ans- sterile solution
TPN is always administered via ___ {{Ans- infusion pump
A mixture of TPN contains ___, ___, ___, ___, ___, ___
{{Ans-
- amino acids
- dextrose
- added electrolytes
- minerals
- vitamins
- fat emulsions can be added although as usually given separately
4 nursing interventions for clients on TPN
{{Ans-
- maintain sterility of solution and infusion site
- monitor BUN levels in patients with impaired kidney functions or liver disease
- monitor blood & urine glucose levels every 6 hours until insulin production adjusts to the increased
glucose infusions
- supplemental insulin may be needed
6 complications from TPN
{{Ans-
- hyperglycemia
- hypoglycemia
- vitamin deficiencies
- air embolism
- infection
- fluid imbalance
3 nursing actions to treat TPN-caused metabolism complications (hyperglycemia, hypoglycemia, vitamin
deficiencies)
{{Ans-
- draw daily labs and get results before a new TPN is made
, - replace fluid deficits with another intravenous site
- monitor for hyperglycemia
3 nursing actions to treat air embolism caused by TPN
{{Ans-
- monitor for signs/symptoms of air embolus
- clamp catheter and lay on left side in Trendelenburg to trap air
- administer oxygen
4 nursing actions to treat infection caused by TPN
{{Ans-
- monitor insertion site for signs/symptoms of infection
- change central line dressing as per protocols (every 48-72 hours)
- monitor for infection
- no other meds are given in same line as TPN !!!!
TPN is ___, which can place clients at risk for fluid shifts causing increased risk of fluid volume excess
{{Ans- hyperosmotic
3 nursing actions to treat fluid imbalance caused by TPN
{{Ans-
- assess lung sounds for crackles & monitor for respiratory distress
- monitor daily weight, I&O
- always run TPN on a pump
Increase ___ to reduce diarrhea caused by enteral feedings or TPN {{Ans- fiber
TPN is only compatible with ___ {{Ans- normal saline
___ is inflammation of the appendix walls {{Ans- appendicitis
5 clinical manifestations of appendicitis
{{Ans-
- RLQ pain
- dull pain around umbilicus
- loss of appetite
- possible nausea/vomiting
- temperature of 99-102 degrees
2 diagnostics for appendicitis
{{Ans-
- CT scan
___ is used when the patient is unable to take in nutritional support orally; administration of
nutritionally balanced and liquified foods {{Ans- enteral tube feeding
___ will be inserted stomach, jejunum, duodenum {{Ans- enteral tube
Clients receiving an enteral tube feeding MUST have ___ {{Ans- a functioning GI tract
When patients are receiving tube feedings, the head of the bed should be elevated to at least ___-___
degrees {{Ans- 30-45
Tube patency must be assessed at least every ___ and/or before and after tube is used for a feeding
{{Ans- 4 hours
Assess ___, ___, ___, ___, ___, ___, ___ every 4 hours, even if patient is on continuous feeds
{{Ans-
- shape & feel of abdomen
- bowel sound presences (all quadrants)
- tenderness upon palpation
- stability of tube (look at marker outside tube)
- daily weights
- accurate I&O
- glucose checks for first 24 hours
pH ___ indicates that the tube is in the stomach (gastrostomy tube) {{Ans- <4
pH ___ indicates the tube is in the jejunum (jejunostomy tube) {{Ans- >6
3 complications of enteral feedings
{{Ans-
- overfeeding (nausea, vomiting, abdominal distention)
- diarrhea/dumping syndrome
- aspiration pneumonia
Assess residuals every ___-___ {{Ans- 4-6 hours
6 nursing actions to treat complications of enteral tube feedings
{{Ans-
- stop feeding
- suction airway while patient is laying on side
- provide oxygen
,- watch for increase in temp. (infection)
- auscultate breath sounds
- chest x-ray
___ is intravenous administration of amino acids, with carbohydrates, fats, electrolytes, vitamins,
minerals; must be administered through a central vein or PICC lines
{{Ans- parenteral tube feedings (TPN)
TPN is usually given IV as a ___ {{Ans- sterile solution
TPN is always administered via ___ {{Ans- infusion pump
A mixture of TPN contains ___, ___, ___, ___, ___, ___
{{Ans-
- amino acids
- dextrose
- added electrolytes
- minerals
- vitamins
- fat emulsions can be added although as usually given separately
4 nursing interventions for clients on TPN
{{Ans-
- maintain sterility of solution and infusion site
- monitor BUN levels in patients with impaired kidney functions or liver disease
- monitor blood & urine glucose levels every 6 hours until insulin production adjusts to the increased
glucose infusions
- supplemental insulin may be needed
6 complications from TPN
{{Ans-
- hyperglycemia
- hypoglycemia
- vitamin deficiencies
- air embolism
- infection
- fluid imbalance
3 nursing actions to treat TPN-caused metabolism complications (hyperglycemia, hypoglycemia, vitamin
deficiencies)
{{Ans-
- draw daily labs and get results before a new TPN is made
, - replace fluid deficits with another intravenous site
- monitor for hyperglycemia
3 nursing actions to treat air embolism caused by TPN
{{Ans-
- monitor for signs/symptoms of air embolus
- clamp catheter and lay on left side in Trendelenburg to trap air
- administer oxygen
4 nursing actions to treat infection caused by TPN
{{Ans-
- monitor insertion site for signs/symptoms of infection
- change central line dressing as per protocols (every 48-72 hours)
- monitor for infection
- no other meds are given in same line as TPN !!!!
TPN is ___, which can place clients at risk for fluid shifts causing increased risk of fluid volume excess
{{Ans- hyperosmotic
3 nursing actions to treat fluid imbalance caused by TPN
{{Ans-
- assess lung sounds for crackles & monitor for respiratory distress
- monitor daily weight, I&O
- always run TPN on a pump
Increase ___ to reduce diarrhea caused by enteral feedings or TPN {{Ans- fiber
TPN is only compatible with ___ {{Ans- normal saline
___ is inflammation of the appendix walls {{Ans- appendicitis
5 clinical manifestations of appendicitis
{{Ans-
- RLQ pain
- dull pain around umbilicus
- loss of appetite
- possible nausea/vomiting
- temperature of 99-102 degrees
2 diagnostics for appendicitis
{{Ans-
- CT scan
