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Chapter 44- GI Chapter 44: Care of the Patient with a Gastrointestinal Disorder | Questions and Verified Answers| 100% Correct| Grade A$7.99
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Chapter 44- GI
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A
A nurse is preparing to place a patient's
ordered nasogastric tube. How should
Feedback:
the nurse best determine the correct
length of the nasogastric tube?
Tube length is traditionally determined by
A)
(1) measuring the distance from the tip
Place distal tip to nose, then ear tip and
of the nose to the earlobe and from the
end of xiphoid process.
earlobe to the xiphoid process, and (2)
B)
adding up to 6 inches for NG placement
Instruct the patient to lie prone and mea-
or at least 8 to 10 inches or more for
sure tip of nose to umbilical area.
intestinal placement, although studies do
C)
not necessarily confirm that this is a reli-
Insert the tube into the patient's nose
able technique. The physician would not
until secretions can be aspirated.
prescribe a specific length and the um-
D)
bilicus is not a landmark for this process.
Obtain an order from the physician for
Length is not determined by aspirating
the length of tube to insert.
from the tube.
A patient is concerned about leakage of
gastric contents out of the gastric sump
B
tube the nurse has just inserted. What
would the nurse do to prevent reflux gas-
Feedback:
tric contents from coming through the
blue vent of a gastric sump tube?
The blue vent lumen should be kept
A)
above the patient's waist to prevent reflux
Prime the tubing with 20 mL of normal
of gastric contents through it; otherwise
saline.
it acts as a siphon. A one-way anti-reflux
B)
valve seated in the blue pigtail can pre-
Keep the vent lumen above the patient's
vent the reflux of gastric contents out the
waist.
vent lumen. To prevent reflux, the nurse
C)
does not prime the tubing, maintain the
Maintain the patient in a high Fowler's
patient in a high Fowler's position, or
position.
have the patient pin the tube to the thigh.
D)
Have the patient pin the tube to the thigh.
A patient receiving tube feedings is ex-
C
periencing diarrhea. The nurse and the
physician suspect that the patient is ex-
Feedback:
periencing dumping syndrome. What in-
, Chapter 44- GI
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tervention is most appropriate?
A)
Stop the tube feed and aspirate stomach Dumping syndrome can generally be al-
contents. leviated by starting with a dilute solution
B) and then increasing the concentration of
Increase the hourly feed rate so it finish- the solution over several days. Fluid re-
es earlier. placement may be necessary but does
C) not prevent or treat dumping syndrome.
Dilute the concentration of the feeding There is no need to aspirate stomach
solution. contents. Increasing the rate will exacer-
D) bate the problem.
Administer fluid replacement by IV
A nurse is admitting a patient to the
postsurgical unit following a gastrostomy.
When planning assessments, the nurse
A
should be aware of what potential post-
operative complication of a gastrosto-
Feedback:
my?
A)
A significant postoperative complication
Premature removal of the G tube
of a gastrostomy is premature removal
B)
of the G tube. Constipation is a less im-
Bowel perforation
mediate threat and bowel perforation and
C)
PUD are not noted to be likely complica-
Constipation
tions.
D)
Development of peptic ulcer disease
(PUD)
A nursing educator is reviewing the care B
of patients with feeding tubes and en-
dotracheal tubes (ET). The educator has Feedback:
emphasized the need to check for tube
placement in the stomach as well as Protecting the client from aspirating is
residual volume. What is the main pur- essential because aspiration can cause
pose of this nursing action? pneumonia, a potentially life-threaten-
A) ing disorder. Gastric ulcers are not a
Prevent gastric ulcers common complication of tube feeding in
B) clients with ET tubes. Abdominal disten-
Prevent aspiration tion and diarrhea can both be associated
, Chapter 44- GI
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C)
with tube feeding, but prevention of these
Prevent abdominal distention
problems is not the primary rationale for
D)
confirming placement.
Prevent diarrhea
The nurse is administering total par-
enteral nutrition (TPN) to a client who
underwent surgery for gastric cancer.
A
Which of the nurse's assessments most
directly addresses a major complication
Feedback:
of TPN?
A)
The solution, used as a base for most
Checking the patient's capillary blood
TPN, consists of a high dextrose con-
glucose levels regularly
centration and may raise blood glucose
B)
levels significantly, resulting in hyper-
Having the patient frequently rate his or
glycemia. This is a more salient threat
her hunger on a 10-point scale
than hunger, though this should be ad-
C)
dressed. Dysrhythmias and decreased
Measuring the patient's heart rhythm at
LOC are not among the most common
least every 6 hours
complications.
D)
Monitoring the patient's level of con-
sciousness each shift
A critical care nurse is caring for a pa-
tient diagnosed with acute pancreatitis.
The nurse knows that the indications for
C
starting parenteral nutrition (PN) for this
patient are what?
Feedback:
A)
5% deficit in body weight compared to
The indications for PN include an inabil-
preillness weight and increased caloric
ity to ingest adequate oral food or flu-
need
ids within 7 days. Weight loss, muscle
B)
wasting combined with electrolyte imbal-
Calorie deficit and muscle wasting com-
ances, and aspiration indicate a need
bined with low electrolyte levels
for nutritional support, but this does not
C)
necessary have to be parenteral.
Inability to take in adequate oral food or
fluids within 7 days
D)
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