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Terms in this set (12)A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes the clients pulse is 128 beats/min, blood pressure is 98/56 mm Hg, and skin turgor is dry. What action should the nurse perform next? a. Assess the 24-hour fluid balance. ANS: A This client has clinical indicators of dehydration, so the nurse calculates the clients 24-hour intake, output, and fluid balance. This information is then reported to the provider. The clients oral cavity assessment may or may not be consistent with dehydration. The nurse may need to give the client a fluid bolus, but not as an independent action. The clients dehydration is most likely due to fluid shifts from the TPN, so turning up the infusion rate would make the problem worse, and is not done as an independent action. A client is receiving total parenteral nutrition (TPN). What action by the nurse is most important? a. Assessing blood glucose as directed ANS: D Clients on TPN are at high risk for infection. The nurse performs appropriate hand hygiene as a priority intervention. Checking blood glucose is also an important measure, but preventing infection takes priority. The IV dressing is changed every 48 to 72 hours. TPN does not need to be double-checked with another nurse. After vertical banded gastroplasty, a 42-year-old male patient returns to the surgical nursing unit with a nasogastric tube to low, intermittent suction and a patient-controlled analgesia (PCA) machine for pain control. Which nursing action should be included in the postoperative plan of care? a.Offer sips of fruit juices at frequent intervals. b.Irrigate the nasogastric (NG) tube frequently. c.Remind the patient that PCA use may slow the return of bowel function. d.Support the surgical incision during patient coughing and turning in bed. ANS: D The incision should be protected from strain to decrease the risk for wound dehiscence. The patient should be encouraged to use the PCA because pain control will improve the cough effort and patient mobility. NG irrigation may damage the suture line or overfill the stomach pouch. Sugar-free clear liquids are offered during the immediate postoperative time to decrease the risk for dumping syndrome. The nurse is caring for a 47-year-old female patient who is comatose and is receiving continuous enteral nutrition through a soft nasogastric tube. The nurse notes the presence of new crackles in the patients lungs. In which order will the nurse take action? (Put a comma and a space between each answer choice [A, B, C, D].) a. Check the patients oxygen saturation. b. Notify the patients health care provider. c. Measure the tube feeding residual volume. d. Stop administering the continuous feeding. ANS:D, A, C, B The assessment data indicate that aspiration may have occurred, and the nurses first action should be to turn off the tube feeding to avoid further aspiration. The next action should be to check the oxygen saturation because this may indicate the need for immediate respiratory suctioning or oxygen administration. The residual volume should be obtained because it provides data about possible causes of aspiration. Finally, the health care provider should be notified and informed of all the assessment data the nurse has just obtained. A nurse is preparing to place a patients 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 patients nose until secretions can be aspirated. D)Obtain an order from the physician for the length of tube to insert. Ans: A 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 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. Ans: C 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.
The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurses assessments most directly addresses a major complication of TPN? A)Checking the patients capillary blood glucose levels regularly B)Having the patient frequently rate his or her hunger on a 10-point scale C)Measuring the patients heart rhythm at least every 6 hours D)Monitoring the patients level of consciousness each shift Ans: A 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 Ans:C 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 creating a care plan for a patient with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube? A)Auscultate the patients abdomen after injecting air through the tube. B)Assess the color and pH of aspirate. C)Locate the marking made after the initial x-ray confirming placement. D)Use a combination of at least two accepted methods for confirming placement. Ans:D There are a variety of methods to check tube placement. The safest way to confirm placement is to utilize a combination of assessment methods. A patients new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patients care plan accordingly. What intervention should the nurse include in the patients plan of care? A)Confirm placement of the tube prior to each medication administration. B)Have the patient sip cool water to stimulate saliva production. C)Keep the patient in a low Fowlers position when at rest. D)Connect the tube to continuous wall suction when not in use Ans:A Each time liquids or medications are administered, and once a shift for continuous feedings, the tube must be checked to ensure that it remains properly placed. If the NG tube is used for decompression, it is attached to intermittent low suction. During the placement of a nasogastric tube the patient should be positioned in a Fowlers position. Oral fluid administration is contraindicated by the patients dysphagia. A patients NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next? A)Withdraw the NG tube 3 to 5 cm and reattempt aspiration. B)Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating. C)Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers. D)Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider. Ans:B When a tube is first noted to be clogged, a 30- to 60-mL syringe should be attached to the end of the tube and any contents aspirated and discarded. Then the syringe should be filled with warm water, attached to the tube again, and a back-and-forth motion initiated to help loosen the clog. Removal is not warranted at this early stage and a flicking motion is not recommended. The tube should not be withdrawn, even a few centimeters. A nurse has obtained an order to remove a patients NG tube and has prepared the patient accordingly. After flushing the tube and removing the nasal tape, the nurse attempts removal but is met with resistance. Because the nurse is unable to overcome this resistance, what is the most appropriate action? A)Gently twist the tube before pulling. B)Instill a digestive enzyme solution and reattempt removal in 10 to 15 minutes. C)Flush the tube with hot tap water and reattempt removal. D)Report this finding to the patients primary care provider. Ans:D If the tube does not come out easily, force should not be used, and the problem should be reported to the primary provider. 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What is the nurse's responsibilities in administering TPN?Educate client on the need for and use of TPN. Apply knowledge of nursing procedures and psychomotor skills when caring for a client receiving TPN. Apply knowledge of client pathophysiology and mathematics to TPN interventions. Administer parenteral nutrition and evaluate client response (e.g., TPN)
What would be the priority nursing intervention for the patient with TPN?Interventions: Strict adherence to aseptic technique with insertion, care, and maintenance; avoid hyperglycemia to prevent infection complications; closely monitor vital signs and temperature. IV antibiotic therapy is required. Monitor white blood cell count and patient for malaise.
What would be the priority nursing consideration when caring for a client receiving TPN?Monitor blood glucose levels. Observe for signs of hyperglycemia or hypoglycemia and administer insulin as directed. (Blood glucose levels may be affected if TPN is turned off, if the rate is reduced, or if excess levels of insulin are added to the solution.) Monitor for signs of fluid overload.
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Which action would the nurse take when administering total parenteral nutrition TPN quizlet?
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