NG TUBE, G-TUBE & ENTERAL NUTRITION
A nurse is preparing to administer medications through an NG tube. Which assessment finding requires immediate intervention?
What is inability to verify tube placement?
Verifying tube placement is a priority before administering medications, feedings, or fluids. If placement cannot be confirmed, the tube should not be used due to the risk of delivering substances into the lungs, which can cause aspiration and respiratory compromise.
A patient receiving TPN has a blood glucose level of 310 mg/dL. Which complication is the nurse monitoring for?
Answer:
What is hyperglycemia?
Rationale:
TPN contains a high concentration of dextrose, which can significantly elevate blood glucose levels. Hyperglycemia is a common complication of TPN and can increase the risk of infection, delayed healing, and dehydration. Regular glucose monitoring is essential.
The nurse removes gloves after caring for a patient with C. difficile. What is the most important next action?
Answer:
What is washing hands with soap and water?
Rationale:
C. difficile forms spores that are not effectively removed by alcohol-based hand sanitizers. Soap and water physically remove spores from the hands.
A patient reports knee pain that worsens throughout the day and improves with rest. Which condition is most likely?
Answer:
What is Osteoarthritis (OA)?
Rationale:
OA is a degenerative joint disease caused by the breakdown of cartilage. Pain typically worsens with activity and improves with rest. It commonly affects weight-bearing joints such as the knees and hips.
A nurse notes unilateral calf swelling, warmth, redness, and tenderness. Which condition should the nurse suspect?
Answer:
What is Deep Vein Thrombosis (DVT)?
Rationale:
DVT occurs when a blood clot forms in a deep vein, most commonly in the leg. Early recognition is important because the clot can dislodge and travel to the lungs.
A patient receiving continuous enteral feedings develops coughing, oxygen saturation of 89%, and crackles in the lungs. What complication should the nurse suspect?
What is aspiration?
Rationale:
Coughing, decreased oxygen saturation, and crackles are classic signs of aspiration. Aspiration occurs when feeding formula enters the respiratory tract and can lead to aspiration pneumonia, respiratory distress, and hypoxia.
A nurse notices that a TPN infusion has stopped because the central line is occluded. What is the greatest immediate concern?
Answer:
What is hypoglycemia?
Rationale:
Patients receiving continuous TPN become accustomed to a steady supply of glucose. If the infusion is interrupted suddenly, blood glucose levels can drop rapidly, resulting in hypoglycemia. Signs include diaphoresis, shakiness, confusion, and altered mental status. Administering D10W provides a temporary source of glucose until the next TPN bag is available, helping to prevent hypoglycemia.
Which patient is at greatest risk for developing C. difficile infection?
A. A healthy 25-year-old receiving IV fluids
B. A 78-year-old receiving broad-spectrum antibiotics
C. A patient with hypertension taking lisinopril
D. A patient admitted for a wrist fracture
Answer:
What is B. A 78-year-old receiving broad-spectrum antibiotics?
Rationale:
Advanced age, hospitalization, and recent antibiotic use are major risk factors for C. difficile infection.
A patient presents with sudden severe pain, redness, and swelling of the great toe after consuming alcohol and red meat. Which condition is most likely?
What is Gout?
Rationale:
Gout occurs when uric acid crystals deposit in joints, causing acute inflammation. Alcohol and foods high in purines can trigger gout attacks.
A patient with a confirmed DVT suddenly develops shortness of breath, chest pain, and tachycardia. What complication should the nurse suspect?
Answer:
What is a Pulmonary Embolism (PE)?
Rationale:
A pulmonary embolism occurs when part of a clot breaks off and travels to the lungs. This is a life-threatening emergency requiring immediate intervention.
The nurse obtains gastric aspirate with a pH of 7.5 from an NG tube. What is the nurse's priority action?
What is hold feedings and further verify placement?
Gastric contents are typically acidic. A pH of 7.5 may indicate the tube is not in the stomach or that stomach acidity has been altered. The nurse should stop feedings and verify placement before using the tube to reduce aspiration risk.
Which assessment finding suggests a catheter-related bloodstream infection in a patient receiving TPN?
Answer:
What is fever and redness at the insertion site?
Rationale:
TPN requires central venous access, placing patients at risk for central line-associated bloodstream infections (CLABSIs). Fever, chills, redness, swelling, tenderness, or drainage at the insertion site warrant immediate evaluation.
A nursing assistant cleans a room of a patient with C. difficile using a standard disinfectant wipe. What should the nurse do?
Answer:
What is instruct the assistant to use a bleach-based sporicidal disinfectant?
Rationale:
C. difficile spores can survive on surfaces for long periods. Bleach-based or EPA-approved sporicidal products are required to kill the spores and prevent transmission.
A nurse is teaching a patient about osteoporosis risk factors. Which factor is non-modifiable?
A. Smoking
B. Sedentary lifestyle
C. Female gender
D. Low calcium intake
Answer:
What is C. Female gender?
Rationale:
Non-modifiable risk factors cannot be changed and include age, female gender, family history, race, and menopause. Smoking, inactivity, and poor nutrition are modifiable risk factors.
A patient receiving insulin becomes confused and difficult to arouse. The patient is NPO. What is the nurse's priority action?
Answer:
What is administer IV dextrose according to protocol?
Rationale:
The patient is showing signs of severe hypoglycemia and cannot safely take oral carbohydrates. IV dextrose is the fastest and safest treatment.
A patient with a recent stroke requires long-term enteral nutrition. Which tube would be most appropriate?
What is a gastrostomy tube (G-tube)?
G-tubes are indicated for patients requiring long-term nutritional support. NG tubes are intended for short-term use and can increase the risk of sinus irritation, skin breakdown, and accidental dislodgement when used for extended periods
A provider orders TPN for a patient with a functioning GI tract. The nurse questions the order because TPN is generally reserved for patients who cannot use which system?
Answer:
What is the gastrointestinal system?
Rationale:
The GI tract should be used whenever possible because it maintains gut integrity and carries fewer risks. TPN is indicated when the GI tract is nonfunctional or cannot absorb nutrients adequately, such as with bowel obstruction, severe malabsorption, or prolonged ileus.
A nurse is caring for four patients. Which patient should be assessed first for possible C. difficile infection?
A. Patient with constipation for 3 days
B. Patient receiving antibiotics with new watery diarrhea
C. Patient with nausea after surgery
D. Patient with chronic GERD
Answer:
What is B. Patient receiving antibiotics with new watery diarrhea?
Rationale:
Watery diarrhea after antibiotic therapy is a hallmark sign of C. difficile and requires prompt assessment and isolation precautions.
A 79-year-old patient takes a proton pump inhibitor daily for GERD and recently sustained a hip fracture. What long-term effect of PPIs may have contributed to this injury?
Answer:
What is decreased calcium absorption leading to osteoporosis?
Rationale:
Long-term PPI use may decrease calcium absorption, increasing the risk of osteoporosis and fractures, particularly in older adults.
A patient on anticoagulant therapy for a DVT reports black, tarry stools. What is the nurse's priority action?
Answer:
What is notify the provider immediately?
Rationale:
Black, tarry stools (melena) may indicate gastrointestinal bleeding, a serious complication of anticoagulant therapy.
A nurse finds the external length of an NG tube has increased by 5 cm since the beginning of the shift. The patient denies discomfort. What is the nurse's priority action?
What is stop feedings and verify placement before use?
A change in the external tube length suggests possible tube migration. Even if the patient has no symptoms, tube displacement can result in feeding into the esophagus or respiratory tract. Placement must be verified before administering feedings or medications.
A nurse caring for a patient receiving TPN notes sudden shortness of breath, chest pain, and tachycardia after central line manipulation. What complication should be suspected?
Answer:
What is an air embolism?
Rationale:
Air can enter the bloodstream if the central venous catheter is opened or improperly handled. Air embolism is a medical emergency that can obstruct blood flow and impair oxygenation. Symptoms include sudden dyspnea, chest pain, tachycardia, and anxiety.
A provider prescribes loperamide (Imodium) for a patient suspected of having C. difficile. What should the nurse do?
Answer:
What is question the order?
Rationale:
Antidiarrheal medications can slow the elimination of C. difficile toxins and may worsen the infection, increasing the risk of toxic megacolon.
A patient prescribed colchicine for gout states, "I drink grapefruit juice every morning." What should the nurse teach?
Answer:
What is "Avoid grapefruit juice while taking colchicine"?
Rationale
Grapefruit juice can increase blood levels of colchicine, leading to toxicity. Grapefruit inhibits the CYP3A4 enzyme and P-glycoprotein system that help metabolize and eliminate colchicine.
A nurse is assessing four patients. Which patient should be seen first?
A. Diabetic patient with a blood glucose of 250 mg/dL
B. Patient with a DVT who reports calf pain rated 6/10
C. Patient with a DVT who suddenly develops shortness of breath
D. Patient with gout reporting toe pain
Answer:
What is C. Patient with a DVT who suddenly develops shortness of breath?
Rationale:
Shortness of breath in a patient with a known DVT may indicate a pulmonary embolism, which is a life-threatening emergency and requires immediate assessment.