The nurse is to discontinue a nasogastric tube
that had been used for decompression. The first
thing the nurse does is:
a. Flush with 10 mL of water
b. Remove the tape from the nose of the
client
c. Withdraw the tube gently for 6 to 8
inches
d. Provide oral hygiene
Gastric decompression – the removing of contents of
the stomach with a nasogastric tube
The nurse is teaching an unlicensed caregiver
about bathing patients who are receiving tube
feedings. Which of the following is the most
significant complication related to continuous
tube feedings?
a. The potential for aspiration
b. A disturbance in the sequence of
intestinal and hepatic metabolism
c. An interruption in fat metabolism and
lipoprotein synthesis
d. The interruption of GI integrity
A client has been receiving intermittent tube
feedings for several days at home. The nurse
notes the findings as shown in the accompanying
documentation. The nurse reports the following
as an adverse reaction to the tube feeding:
a. Liver function tests
b. Physical assessment data
c. Fasting blood glucose level
d. Renal studies
Intermittent feeding – EN (enteral feeding) is
administered over 20-60 minutes every 4-6 hours with
or without a feeding pump
Bolus feeding – EN is administered via syringe or
gravity drip over a 4-10 minute period
Enteral feeding – may mean nutrition taken through
the mouth or a tube that goes directly to the stomach
or small intestine; a form of nutrition that is delivered
into the digestive system as liquid
Parenteral feeding – feeding intravenously (through a
vein); outside of the digestive tract; bypasses the
entire digestive system, from mouth to anus
The patient is on a continuous tube feeding. The
tube placement should be checked every:
Answer: Flush with 10 mL of water
R: Before a nasogastric tube is removed, the
nurse flushes the tube with 10 mL of water or
normal saline to ensure that the tube is free of
debris and away from the gastric tissue. The
tape keeps the tube in the correct position while
flushing is occurring and is then removed from
the nose. The nurse then withdraws the tube
gently for 6 to 8 inches until the tip reaches the
esophagus, and then the remainder of the tube is
withdrawn rapidly from the nostril. After the tube
is removed, the nurse provides oral hygiene.
Answer: The potential for aspiration
R: Because the normal swallowing mechanism is
bypassed (evaded/avoided), consideration of the
danger of aspiration must be foremost in the
mind of the nurse caring for the patient receiving
continuous tube feedings. Tube feedings
preserve GI integrity by intraluminal delivery of
nutrients. Tube feedings preserve the normal
sequence of intestinal and hepatic metabolism.
Tube feedings maintain fat metabolism and
lipoprotein synthesis.
Answer: Fasting blood glucose level
R: An adverse reaction to tube feedings is an
elevated blood glucose level. The physical
assessment data and renal function and liver
function studies are normal.
Answer: shift
 a. Hour R: Each nurse caring for the patient is responsible
b. 24 hours for verifying that the tube is located in the proper
c. Shift area for continuous feeding. Checking for
d. 12 hours placement each hour is unnecessary unless the
patient is extremely restless or there is basis for
rechecking the tube based on other patient
activities. Checking for placement every 12 to 24
hours does not meet the standard of care due the
patient is receiving continuous tube feedings.
Which of the following is caused by improper Answer: Pneumothorax
catheter placement and inadvertent puncture of
the pleura? R: A pneumothorax is caused by improper
a. Air embolism catheter placement and inadvertent puncture of
b. Pneumothorax the pleura. Air embolism can occur from a
c. Fluid overload missing cap on a port. Sepsis ca be caused by the
d. Sepsis separation of dressings. Fluid overload is caused
by fluids infusing too rapidly.
Inadvertent – not resulting from or achieved through
deliberate planning; unintentional, unintended,
accidental
Pleura – each pair of serous membranes lining the
thorax and enveloping the lungs in humans
A client has a gastrointestinal tube that enters Answer: Gastrostomy tube
the stomach through a surgically created opening
in the abdominal wall. The nurse documents this R: A gastrostomy tube enters the stomach
as which of the following? through a surgically created opening into the
a. Nasogastric tube abdominal wall.
b. Jejunostomy tube
c. Orogastric tube A jejunostomy tube enters jejunum or small
d. Gastrostomy tube intestine through a surgically created opening
into the abdominal wall.

A nasogastric tube passes through the nose into

the stomach via the esophagus.

An orogastric tube passes through the mouth

The nurse is to insert a post-pyloric feeding tube.
One way that the nurse can aid in placement past
the pylorus is to:
a. Assist the client to drink 8 ounces of
water
b. administer prescribed metoclopramide
(Reglan)
c. have the client lay on his left side
d. instruct the client to swallow several
times
into the stomach.
Answer: Administer prescribed metoclopramide
(Reglan)
R: Metoclopramide (Reglan) is administered to
increase peristalsis of the feeding tube into the
duodenum. Placing the client on his right side,
not the left side, helps to facilitate movement
and placement. Having the client swallow or even
to drink water facilitates placement of the tube
past the epiglottis, not into the duodenum.
Post-pyloric feeding – refers to feeding beyond the
pylorus, either into the duodenum, or more ideally into
the jejunum; good for disease states that slow gastric
emptying because it bypasses the stomach; prevents
aspiration
Initially, which diagnostic should be completed
following placement of a NG tube?
a. X-ray
b. pH measurement of aspirate
c. measurement of tube length
d. visual assessment of aspirate
A patient has just had a nasogastric tube (NG)
inserted and the nurse is waiting for verification
of placement of the tube prior to starting tube
feedings. Which is the best method of verification
the nurse should use for determining new NG
tube placement?
a. Observing gastric aspirate
b. Gastric aspirate pH testing
c. Air auscultation
d. X-ray confirmation
Which of the following is the gold standard for
assessing the placement of a nasogastric (NG)
tube for the patient receiving feedings?
Answer: X-ray
R: Initially, an X-ray should be used to confirm
tube placement. Subsequently, each time liquids
or medications are administered, as well as once
per shift for continuous feedings, a combination
of three methods is recommended:
measurement of tube length, visual assessment
of aspirate, and pH measurement of aspirate.
Answer: X-ray confirmation
R: Radiologic identification of tube placement in
the stomach is the most reliable method.
Gastric fluid may be grassy green, brown, clear,
or odorless, whereas an aspirate from the lungs
may be off-white or tan. Hence, checking aspirate
is not the best method of determining NG tube
placement in the stomach.
Gastric pH values are typically lower or more
acidic than that of the intestinal or respiratory
tract, but not always.
Air auscultation is not a reliable method for
determining NG tube placement in the stomach
when used alone.
Answer: X-ray
R: The gold standard for verifying placement o a
 a. Use of capnographic device blindly inserted tube is radiographic or X-ray
b. pH testing confirmation. X-ray confirmation is necessary if
c. visual assessment of aspiration the patient will be receiving feedings or
d. X-ray medications through the tube.

When the tube is used to remove air or fluid and

not for instillation, the nurse can use a
combination of visually assessing the aspirate,
testing its pH, and using capnographic devices to
initially determine placement.
The patient is on a continuous tube feeding. How Answer: Every shift
often should the tube placement be checked?
a. Every hour
b. Every 24 hours
c. Every shift
d. Every 12 hours
The nurse prepares to give a bolus tube feeding Answer: Reassess the residual gastric content in 1
to the patient and determines that the residual hour
gastric content is 150 cc. The priority nursing
action is to R: If the gastric residual exceeds 100 cc for 2
a. Give the tube feeding hours in a row, the physician should be notified.
b. Reassess the residual gastric content in 1 One observation of a residual gastric content
hour over 100 cc does not have to be reported to the
c. Withhold the tube feeding indefinitely physician. If the observation occurs two times in
d. Notify the physician succession, the physician should be notified.

If the amount of gastric residual exceeds 100 cc,

As part of the process of checking the placement
of a nasogastric tube, the nurse checks the pH of
the aspirate. Which pH finding would indicate to
the nurse that the tube is in the stomach?
a. 6
b. 4
c. 8
d. 10
The nurse assesses a patient who recently had
nasoenteric intubation. Symptoms of oliguria,
lethargy, and tachycardia in the patient would
indicate to the nurse what common
complication?
a. Pulmonary complications
b. Fluid volume deficit
c. Mucous membrane irritation
d. A cardiac dysrhythmia
the tube feeding should be withheld at that time,
but not indefinitely.
Answer: 4
R: Gastric secretions are acidic and have a pH
ranging for 1 to 5. Intestinal aspirate is typically 6
or higher; respiratory aspirate is more alkaline,
usually 7 or greater.
Answer: Fluid volume deficit
R: Symptoms of fluid volume deficit include dry
skin and mucous membranes, decreased urinary
output, lethargy, lightheadedness, hypotension,
and increased heart rate.

Oliguria – urine production below 0.5 mL/kg/hr for

more than 2 hours; urine output less than 400 – 500
mL/day; clinically 80 – 400 mL/day
The nurse on an evidence-based practice council
is making recommendations to ensure patency of
nontunneled central venous lines. The nurse
recommends that daily saline and diluted heparin
flushes be used in which of the following
situation?
a. Before drawing blood
b. With continuous infusions
c. Daily when not in use
d. When the line is discontinued
Nontunneled central venous lines – most common in
acute care settings; highest rate of infection; a type of
short-term IV catheter, may be put into a large vein
near the neck, chest, or groin
The primary source of microorganisms for
catheter-related infections includes the skin and
which of the following?
a. IV fluid bag
b. Catheter hub
c. IV tubing
d. Catheter tubing
The nurse checks residual content before each
intermittent tube feeding. When should the
patient be reassessed?
a. When the residual is greater than 200 mL
b. When the residual is between 50 and 80
mL
c. When the residual is about 50 mL
d. When the residual is about 100 mL
The client is experiencing swallowing difficulties
and is now scheduled to receive a gastric feeding.
She has the following oral medications
Answer: Daily when not in use
R: Daily instillation of normal saline and diluted
heparin flush when a nontunneled central
catheter is not in use will maintain the line’s
patency. Continuous infusion maintains the
patency of the line. Normal saline and heparin
flushes should be used after each time blood is
drawn in order to prevent clotting of blood within
the line. Normal saline and heparin flush are not
needed when a line is being discontinued.
Answer: Catheter hub
R: The primary source of microorganisms for
catheter-related infections are the skin and the
catheter hub. The catheter site is covered with an
occlusive gauze dressing that is usually changed
every other day.
Answer: When the residual is greater than 200
mL
R: Although a residual volume of 200 mL or
greater is generally considered a cause for
concern in patients at high risk for aspiration,
feedings do not necessarily need to be withheld
in all patients.
Answer: Enteric coated aspirin
R: Simple compressed tablets (furosemide,
prescribed: furosemide (Lasix), digoxin, enteric
coated aspirin (Ecotrin), and vitamin E. The nurse
withholds
A. Enteric coated aspirin
B. Digoxin
C. Furosemide
D. Vitamin E
A patient has a gastric sump tube inserted and
attached to low intermittent suction. The
physician has ordered the tube to be irrigated
with 30 mL of normal saline every 6 hours. When
reviewing the patient’s intake and output record
for the past 24 hours, the nurse would expect to
note that the patient received how much fluid
with the irrigation?
A client recovering from gastric bypass surgery
accidently removes the nasogastric tube. It is best
for the nurse to
a. Place the nasogastric tube to the level of
the esophagus
b. Document the discontinuation of the
nasogastric tube
c. Notify the surgeon about the tube’s
removal
d. Reinsert the nasogastric tube to the
stomach
The nurse is administering a tube feeding to a
patient via intermittent gravity drip method. The
nurse should administer the feeding over at least
which period of time?
a. 60 minutes
b. 80 minutes
c. 30 minutes
d. 15 minutes
Intermittent gravity drip feeding – administered every
4-6 hours in equal portion of 200-300 mL over a 30–
60-minute time frame via gravity drip
The nurse is monitoring a patient with
nasoenteric intubation. The nurse contacts the
physician when which of the following is noted?
a. Blood pressure 118/72
b. Moist mucous membranes
c. Heart rate of 100
digoxin) may be crushed and dissolved in water.
Soft gelatin capsules filled with liquid (vitamin E)
may be opened, ad the contents squeezed out.
Enteric coated tablets (enteric coated aspirin) are
not to be crushed and a change in the form of
medications is required.
Answer: 120
R: The patient receives 30 mL every 6 hours. So
over a 24-hour period, the patient would receive
4 irrigations. 4 times 30 mL equals 120 mL.
Answer: Notify the surgeon about the tube’s
removal
R: If the nasogastric tube is removed accidentally
in a client who has undergone esophageal or
gastric surgery, it is usually replaced by the
physician.
Care is taken to avoid trauma to the suture line.
The nurse will not insert the tube to the
esophagus or to the stomach in this situation.
The nurse needs to do more than just document
its removal. The nurse needs to notify the
physician who will make a determination of
leaving out or inserting a new nasogastric tube.
Answer: 30 minutes
R: Tube feedings administered via intermittent
gravity drip should be administered over 30
minutes or longer.
Answer: Urinary output of 20 mL/hour
R: The nurse should notify the physician when
the patient has a urinary output of 20 mL/hr as
this is a decreased urinary rate. Decreased
urinary output, lethargy, lightheadedness,
 d. Urinary output of 20 mL per hour
The physician orders the insertion of a single
lumen nasogastric tube. When gathering the
equipment for the insertion, the nurse would
select which of the following?
a. Miller-Abbott tube
b. Levin tube
c. Sengsten-Blakemore tube
d. Salem pump tube
hypotension, and increased heart rate are signs
and symptoms of fluid volume deficit.
Answer: Levin tube
R: A Levin tube is a single lumen nasogastric tube.
A Salem sump tube is a double lumen nasogastric
tube; a Sengsten-Blakemore tube is a triple
lumen nasogastric tube. A Miller-Abbott is a
double lumen nasoenteric tube.

Levin tube – nasogastric tube (feeding and suctioning);

drains fluid and gas from the stomach; no continuous
irrigation; low suction to prevent gastric irritation; one
lumen into the stomach via mouth or nose.
Lumen – part of a catheter used to give treatments or
take blood, having more than one lumen means your
nurse can give 2-3 different IV treatments at the same
time.

The nurse is preparing to administer all of a Answer: Enteric-coated tablets

patient’s medications via feeding tube. The nurse
consults the pharmacist and/or physician when
the nurse notes on the patient’s medication
administration record which of the following
types of oral medication?
R: Enteric-coated tablets are meant to be
digested in the intestinal tract and may be
destroyed by stomach acids. A change in the form
of medication is necessary for patients with tube
 a. Enteric-coated tablets
b. Simple compressed tablets
c. Soft gelatin capsules filled with liquid
d. Buccal or sublingual tablets
When assisting with the plan of care for a client
receiving tube feedings, which of the following
would the nurse include to reduce the client's risk
for aspiration?
a. Aspirating for residual contents every 4
to 8 hours
b. Keeping the client in a semi-Fowler’s
position at all times
c. Giving the feedings at room temperature
d. Administering 15 to 30 mL of water every
4 hours
The most significant complication related to
continuous tube feedings is
a. A disturbance in the sequence of
intestinal and hepatic metabolism
b. An interruption in fat metabolism and
lipoprotein synthesis
c. The potential for aspiration
d. The interruption of GI integrity
Aspiration – the accidental breathing in of food or
fluid or other materials into the lungs
A nonresponsive client has a nasogastric tube to
low intermittent suction due to gastrointestinal
bleeding. It is most important for the nurse to
a. Auscultate lung sounds every 4 hours
b. Inspect the nose daily for skin irritation
c. Apply water-based lubricant to the nares
daily
d. Change the nasal tape every 2 to 3 days
A nurse prepares a patient for insertion of a
nasoenteric tube. What position should the nurse
place the patient in?
a. Flat in bed
feedings. Simple compressed tablets may be
crushed and dissolved in water for patients
receiving oral medications by feeding tube.
Buccal or sublingual tablets are absorbed by
mucous membranes and may be given as
intended to the patient undergoing tube
feedings. The nurse may make an opening in the
capsule and squeeze out contents for
administration by feeding tube.
Answer: Keeping the client in a semi-Fowler’s
position at all times
R: With continuous tube feedings, the nurse
needs to keep the client in a semi-Fowler's
position at all times to reduce regurgitation and
the risk for aspiration.
Aspirating for residual contents helps to ensure
adequate nutrition and prevent overfeeding.
Administering 15 to 30 mL of water every 4 hours
helps to maintain tube patency. Giving the
feedings at room temperature reduces the risk
for diarrhea.
Answer: the potential for aspiration
R: Because the normal swallowing mechanism is
bypassed, consideration of the danger of
aspiration must be foremost in the mind of the
nurse caring for the patient receiving continuous
tube feedings. Tube feedings preserve GI
integrity by intraluminal delivery of nutrients.
Tube feedings preserve the normal sequence of
intestinal and hepatic metabolism. Tube feedings
maintain fat metabolism and lipoprotein
synthesis.
Answer: Auscultate lung sounds every 4 hours
R: Pulmonary complications may occur as a result
of nasogastric intubation. It is a high priority
according to Maslow's hierarchy of needs and
takes a higher priority over assessing the nose,
changing nasal tape, or applying a water-based
lubricant.
Answer: in high-Fowler’s position
R: During insertion, the patient usually sits
upright (high-Fowler’s position) with a towel or
 b. On his or her right side
c. In semi-Fowler’s position with his or her
head turned to the left
d. In high-Fowler’s position
A client has been prescribed a protein intake of
0.6 g/kg of body weight. The client weighs 154
pounds. The nurse calculates the daily protein
intake to be how many grams? Enter the correct
number ONLY.
A nurse is inserting a nasogastric tube in an alert
client. During the procedure, the client begins to
cough constantly and has difficulty breathing. The
nurse suspects the nasogastric tube is
a. Coiling in the client’s mouth
b. Irritating the epiglottis
c. Inserted into the lungs
d. Passing into the esophagus
The client has the intake and output shown in the
accompanying chart for an 8-hour shift. What is
the positive fluid balance?
A nurse suspects that a patient is developing
rebound hypoglycemia secondary to parenteral
nutrition being discontinued too rapidly. Which
of the following would support the nurse's
suspicions? Select all that apply.
a. Weakness
b. Confusion
c. Dry, hot skin
d. Reports of feeling flushed
e. Tachycardia
f. Shakiness
To ensure patency of central venous line ports,
diluted heparin flushes are used in which of the
following situations?
a. Daily when not in use
b. When the line is discontinued
c. With continuous infusions
d. Before drawing blood
other protective barrier spread in a biblike
fashion over the chest.
Answer: 42
R: The client's weight of 154 pounds is equal to
70 kg. The client is to receive 0.6 g of protein for
each 1 kg of body weight. 0.6 g/kg x 70 kg = 42
grams.
Answer: Inserted into the lungs
R: The alert client may cough constantly and have
difficulty with respirations when the nasogastric
tube enters the lungs. The client may cough but
will not have difficulty with respirations with the
nasogastric tube coiling in the mouth or irritating
the epiglottis. Usually if the nasogastric tube is
entering the esophagus, the client will not exhibit
coughing or dyspnea.
Answer: 260
R: Intake includes all the components listed in the
intake column, which amounts to 710 mL. The
output, which is the urine of 450 mL, is
subtracted from the total intake. This leaves 260
mL as a positive fluid balance.
Answers:
Shakiness
Tachycardia
Weakness
Confusion
R: Signs and symptoms of rebound hypoglycemia
include weakness, faintness, sweating, shakiness,
feeling cold, confusion, and increased heart rate.
Answer: Daily when not in use
R: Daily instillation of dilute heparin flush when a
port is not in use will maintain the port.
Continuous infusion maintains the patency of
each port. Heparin flushes are used after each
intermittent infusion. Heparin flushes are used
after blood drawing to prevent clotting of blood
within the port. Heparin flush of ports is not

Rebound hypoglycemia is a complication of
parenteral nutrition caused by which of the
following?
a. Feedings stopped too abruptly
b. Fluid infusing rapidly
c. Cap missing from the port
d. Glucose intolerance
A client with a gastrojejunostomy is beginning to
take solid food. Which finding would lead the
nurse to suspect that the client is experiencing
dumping syndrome?
a. Slowed heart beat
b. Dry skin
c. Diarrhea
d. Hyperglycemia
Hickman and Groshong are examples of which
type of central venous access device?
a. Nontunneled central catheter
b. Peripherally inserted central catheters
(PICC)
c. Tunneled central catheters
d. Implanted ports
necessary if a line is to be discontinued.
Answer: Feedings stopped too abruptly
R: Rebound hypoglycemia occurs when the
feedings are stopped too abruptly.
Hyperglycemia is caused by glucose intolerance.
Fluid overload is caused by fluids infusing too
rapidly. An air embolism can occur from a cap
missing on a port.
Answer: Diarrhea
R: Clients with a gastrojejunostomy are at risk for
developing the dumping syndrome when they
begin to take solid food. This syndrome produces
weakness, dizziness, sweating, palpitations,
abdominal cramps, and diarrhea, which result
from the rapid emptying (dumping) of large
amounts of hypertonic chyme (a liquid mass of
partly digested food) into the jejunum. This
concentrated solution in the gut draws fluid from
the circulating blood into the intestine, causing
hypovolemia. The drop in blood pressure can
produce syncope. As the syndrome progresses,
the sudden appearance of carbohydrates in the
jejunum stimulates the pancreas to secrete
excessive amounts of insulin, which in turn
causes hypoglycemia.
Answer: Tunneled central catheters
R: Hickman and Groshong catheters are examples
of tunneled central catheters. MediPort is an
implanted port. A percutaneous subclavian Arrow
is an example of a nuntunneled central catheter.
A PICC line is used for intermediate-term IV
therapy for the hospital, long-term care, or the
home setting.

A client who can't tolerate oral feedings begins
receiving intermittent enteral feedings. When
monitoring for evidence of intolerance to these
feedings, the nurse must remain alert for:
a. Constipation, dehydration, and
hypercapnia
b. Manifestations of electrolyte
disturbances
c. Diaphoresis, vomiting, and diarrhea
d. Manifestations of hypoglycemia
Diaphoresis – excessive sweating (often at rest)
The nurse is managing a gastric (Salem) sump
tube for a patient who has an intestinal
obstruction and will be going to surgery. What
interventions should the nurse perform to make
sure the tube is functioning properly?
a. Tape the tube to the head of the bed to
avoid dislodgement
b. Irrigate only through the vent lumen
c. Keep the vent lumen above the patient’s
waist to prevent gastric content reflux
d. Maintain intermittent or continuous
Tunneled CVC’s (central venous catheters) – are
placed under the skin and are meant to be used for a
longer duration of time; they travel under the skin and
terminate away from the venous access site; can be in
place for weeks to months
Nontunneled CVCs’ – are designed to be temporary
and may be put into a large vein near your neck chest
or groin; must be exchanged every few days to a week
Answer: Diaphoresis, vomiting, and diarrhea
R: The nurse must monitor for diaphoresis,
vomiting, and diarrhea because these signs
suggest an intolerance to the ordered enteral
feeding solution. Other signs and symptoms of
feeding intolerance include abdominal cramps,
nausea, aspiration, and glycosuria. Electrolyte
disturbances, constipation, dehydration, and
hypercapnia are complications of enteral
feedings, not signs of intolerance. Hyperglycemia,
not hypoglycemia, is a potential complication of
enteral feedings.
Answer: Keep the vent lumen above the patient’s
waist to prevent gastric content reflux
R: 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.
 suction at a rate greater than 20 mm Hg
Semi-Fowler's position is maintained for at least
which timeframe following completion of an
intermittent tube feeding?
a. 2 hours
b. 1 hour
c. 90 minutes
d. 30 minutes
. The nurse is inserting a sump tube in a patient
with Crohn's disease who is suspected of having a
bowel obstruction. What does the nurse
understand is the benefit of the gastric (Salem)
sump tube in comparison to some of the other
tubes?
A. The tube is radiopaque
B. The tube is shorter
C. The tube can be connected to suction
and others cannot
D. The tube is less expensive
A nurse is caring for a client with a long-term
central venous catheter. Which care principle is
correct?
a. If the needle becomes contaminated
before accessing the port, clean the
needle with povidone-iodine solution
b. Clean the port with an alcohol pad before
administering I.V. fluid through the
catheter
c. If unsuccessful with the first attempt to
access the catheter, reuse the needle and
try again
d. Use clean technique when assessing the
port with a needle
The client is receiving 50% dextrose parenteral
nutrition with fat emulsion therapy through a
peripherally inserted central catheter (PICC). The
nurse has developed a care plan for the nursing
diagnosis “Risk for infection related to
contamination of the central catheter site or
infusion line.” The nurse includes the
intervention
a. Change the transparent dressing every 3
days
b. Assess the PICC insertion site daily
Answer: 1 hour
R: The semi-Fowler’s position is necessary for an
NG feeding, with the patient’s head elevated at
least 30 to 45 degrees to reduce the risk for
reflux and pulmonary aspiration. This position is
maintained for at least 1 hour after completion of
an intermittent tube feeding and is maintained at
all times for patients receiving continuous tube
feedings.
Answer: The tube is radiopaque
R: The gastric (Salem) sump tube is a radiopaque
(easily seen on x-ray), clear plastic, double-lumen
nasogastric tube.
Answer: Clean the port with an alcohol pad
before administering I.V. fluid through the
catheter
R: The nurse should clean the port with an
alcohol pad before administering I.V. fluid
through the catheter to prevent microorganisms
from entering the blood stream. Using clean
technique when assessing the port with a needle,
cleaning the needle with a povidone-iodine
solution, or reusing a needle would break sterile
technique.
Answer: Wear a face mask during dressing
changes
R: The Centers for Disease Control and
Prevention (CDC) recommends changing central
vascular access device dressings every 7 days.
During dressing changes, the nurse and client
wear face masks to reduce the possibility of
airborne contamination. The transparent dressing
allows for frequent assessments of the site. This
is to be done more frequently than daily. During
 c. Use clean gloves when providing site care
d. Wear a face mask during dressing
changes
The nurse is inserting a nasogastric tube and the
patient begins coughing and is unable to speak.
What does the nurse suspect has occurred?
a. The nurse has inadvertently inserted the
tube into the trachea
b. The nurse has inserted a tube that is too
large for the patient
c. This is a normal occurrence and the tube
should be left in place
d. The tube is most likely defective and
should be immediately removed
The nurse is conducting discharge education for a
patient who is to go home with parenteral
nutrition (PN). The nurse sees that the patient
understands the education when the patient
indicates which of the following is a sign and/or
symptom of metabolic complications?
a. Loose, watery stools
b. Decreased pulse rate
c. Increased urination
d. Elevated blood pressure
The client cannot tolerate oral feedings due to an
intestinal obstruction and is NPO. A central line
has been inserted, and the client is being started
on parenteral nutrition (PN). The nurse performs
the following actions while the client receives PN
(select all that apply):
a. Cover insertion site with a transparent
dressing that is changed daily
b. Weigh the client every day
c. Document intake and output
d. Use clean technique for all catheter
dressing changes
e. Check blood glucose level every 6 hours
A client is receiving parenteral nutrition (PN)
through a peripherally inserted central catheter
(PICC) and will be discharged home with PN. The
dressing changes, the nurse wears sterile gloves.
Answer: The nurse has inadvertently inserted the
tube into the trachea
R: To ensure patient safety, it is essential to
confirm that the tube has been placed correctly.
The tube tip may be in the esophagus, stomach,
or small intestine, or inadvertently inserted in the
lungs, most commonly in the right main
bronchus. Inappropriate placement may occur in
patients with decreased level of consciousness,
confused mental states, poor or absent cough
and gag reflexes, or agitation during insertion.
Trachea – the airway that leads from the larynx
(voice box) to the bronchi (large airways that lead
to the lungs)
Answer: Loose, watery stools
R: When the patient indicates that loose watery
stools are a sign/symptom of metabolic
complications, the nurse evaluates that the
patient understands the teaching of metabolic
complications. Signs and symptoms of metabolic
complications from PN include neuropathies,
mentation changes, diarrhea, nausea, skin
changes, and decreased urine output.
Answers:
Weigh the client every day
Document intake and output
Check blood glucose level every 6 hours
R: When a client is receiving PN through a central
line, the nurse weighs the client daily, checks
blood glucose level every 6 hours, and
documents intake and output. These actions are
to ensure the client is receiving optimal nutrition.
The nurse also performs activities to prevent
infection, such as covering the insertion site with
a transparent dressing that is changed weekly
and/or prn and using sterile technique during
catheter site dressing changes.
Answer: No land line; cell phone available and
taken by family member during working hours
home health nurse evaluates the home setting
and makes a recommendation when noting the
following:
a. No land line; cell phone available and
taken by family member during working
hours
b. Water of low pressure can be obtained
through all faucets
c. Little food in the working refrigerator
d. Electricity that loses power, usually for
short duration, during storms
A client is recovering from percutaneous
endoscopic gastrostomy (PEG) tube placement.
The nurse
a. Maintains a gauze dressing over the site
for 3 days
b. Administers an initial bolus of 50 mL
water
c. Pushes the stabilizing disk firmly against
the skin
d. Immediately starts the prescribed tube
feeding
The nurse is caring for a patient who has
dumping syndrome from high carbohydrate
foods being administered over a period of less
than 20 minutes. What is a nursing measure to
prevent or minimize the dumping syndrome?
a. Administer the feeding at a warm
temperature to decrease peristalsis
b. Administer the feeding with the patient
in semi-Fowler’s position to decrease
transit time influenced by gravity
c. Administer the feeding by bolus to
prevent continuous intestinal distention
d. Administer the feeding with about 100
mL of fluid to dilute the high
carbohydrate concentration
The nurse is inserting a nasogastric tube for a
patient with pancreatitis. What intervention can
the nurse provide to allow facilitation of the tube
R: A telephone is necessary for the client
receiving PN for emergency purposes. Water,
refrigeration, and electricity are available, even if
the circumstances are not optimal.
Answer: Administers an initial bolus of 50 mL
water
R: The first fluid nourishment may consist of
water, saline, or 10% dextrose. This may be
administered as a bolus of 30 to 60 mL. By the
second day, formula feeding may begin. A gauze
dressing is applied between the tube insertion
site and the gastrostomy tube. The dressing is
changed daily or as needed. The nurse gently
manipulates the stabilizing disk daily to prevent
skin breakdown.
Answer: Administer the feeding with the patient
in semi-Fowler’s position to decrease transit time
influenced by gravity
R: The following strategies may help prevent
some of the uncomfortable signs and symptoms
of dumping syndrome related to tube feeding:
Slow the formula instillation rate to provide time
for carbohydrates and electrolytes to be diluted.
Administer feedings at room temperature,
because temperature extremes stimulate
peristalsis. Administer feeding by continuous drip
(if tolerated) rather than by bolus, to prevent
sudden distention of the intestine. Advise the
patient to remain in semi-Fowler's position for 1
hour after the feeding; this position prolongs
intestinal transit time by decreasing the effect of
gravity. Instill the minimal amount of water
needed to flush the tubing before and after a
feeding, because fluid given with a feeding
increases intestinal transit time.
Answer: Allow the patient to sip water as the
tube is being inserted
insertion?
a. Spray the oropharynx with an anesthetic
spray
b. Have the patient maintain a backward tilt
head position
c. Allow the patient to sip water as the tube
is being inserted
d. Have the patient eat a cracker as the
tube is being inserted
The nurse is caring for a patient who is at
receiving continuous enteral tube feedings who is
at low risk for aspiration. The nurse assesses the
gastric residual volume to be 350 mL. Which of
the following is the correct action by the nurse?
a. Lower the head of the bed
b. Flush the feeding tube
c. Increase the feeding rate
d. Monitor the feeding closely
The client has just had a central line inserted for
parenteral nutrition. The client is awaiting
transport to the Radiology Department for
catheter placement verification. The client
reports feeling anxious. Respirations are 28
breaths/minute. The first action of the nurse is
a. Auscultate lung sounds
b. Elevate the head of the bed
c. Position the client flat in bed
d. Consult with the healthcare provider
A patient is receiving a continuous tube feeding
via an open delivery system. The patient is to
receive 480 mL in 24 hours. The maximum
amount of formula in the bag should not exceed
which amount?
a. 120 mL
b. 50 mL
c. 240 mL
R: During insertion, the patient usually sits
upright with a towel or other protective barrier
spread in a biblike fashion over the chest.
The nostril may be swabbed or the oropharynx
sprayed with an anesthetic agent to numb the
nasal passage and suppress the gag reflex.
The tip of the patient's nose is tilted upward, and
the tube is aligned to enter the nostril.
When the tube reaches the nasopharynx, the
patient is instructed to lower the head slightly
and, if able, to begin to swallow as the tube is
advanced.
The patient may also be encouraged to sip water
through a straw to facilitate advancement of the
tube if this action is not contraindicated.
Answer: Monitor the feeding closely
R: High residual volumes (>200 mL) should alert
the nurse to monitor the patient more closely.
Increasing the feeding rate will increase the
residual volume. Lowering the head of the bed
increases the patient's risk for aspiration.
Answer: Auscultate lung sounds
R: Following placement of a central line, the
client is at risk for a pneumothorax. The client's
report of anxiety and increased respiratory rate
may be the first signs and symptoms of a
pneumothorax. The nurse first assesses the client
by auscultating lung sounds. Other actions
include placing the client in Fowler's position and
consulting with the healthcare provider about
findings.
Answer: 80 mL
R: When using an open delivery system, bacterial
contamination is possible. Therefore, the amount
of feeding formula in the bag should never
exceed what should be infused in a 4-hour
period. In this case that amount would be 80 mL.
(480 mL divided by 24 hours equals 20 mL per
 d. 80 mL
A nurse is caring for a patient with a Salem pump
gastric tube attached to low intermittent suction
for decompression. The patient acts, “What is the
blue part of the tube for?” Which response by
the nurse would be most appropriate?
a. “It is a vent that prevents backflow of the
secretions.”
b. “It works as a marker to make sure that
the tube stays in place.”
c. “It acts as a siphon, pulling secretions
into the clear tubing.”
d. “It helps regulate the pressure on the
suction machine.”
The nurse is caring for a comatose patient and
administering gastrostomy feedings. What does
the nurse understand is the reason that
gastrostomy feedings are preferred to
nasogastric (NG) feedings in the comatose
patient?
a. Gastroesophageal sphincter is intact,
lessening the possibility of regurgitation
b. The patient cannot experience the
deprivational stress of not swallowing
c. Digestive process occurs more rapidly
because feedings do not have to pass
through the esophagus
d. Feedings can be administered with the
patient in the recumbent position
A patient is receiving nasogastric tube feedings.
The intake and output record for the past 24
hours reveals an intake of 3100 mL and an output
of 2400 mL. The nurse identifies which nursing
diagnosis as most likely?
a. Excess fluid volume
b. Risk for imbalanced nutrition, more than
body requirements
c. Deficient fluid volume
d. Impaired urinary elimination
A patient is to receive parenteral nutrition. The
duration of therapy is planned for 4 weeks. The
nurse develops a teaching plan for the patient to
prepare for insertion of which of the following as
most likely?
A. Peripherally inserted central catheter
B. Implanted port
hour. 20 mL times 4 hours equals 80 mL.)
Answer: “It is a vent that prevents backflow of
the secretions.”
R: The blue part of the Salem sump tube vents
the larger suction-drainage tube to the
atmosphere and, when kept above the patient’s
waist, prevents reflux of gastric contents through
it. Otherwise it acts as a siphon. A gauge on the
suction device regulates the pressure of the
device. The tube has markings on it to aid in
measurement.
Answer: Gastroesophageal sphincter is intact,
lessening the possibility of regurgitation
R: Gastrostomy is preferred over NG feedings in
the patient who is comatose because the
gastroesophageal sphincter remains intact,
making regurgitation and aspiration less likely.
Answer: Excess fluid volume
R: The patient's intake and output record reflects
a greater intake than output, suggesting excess
fluid volume. No information suggests that the
patient's nutritional balance is at risk, even with
nasogastric tube feedings. Deficient fluid volume
would be appropriate if the patient's output
exceeded input. No information indicates that
the patient is experiencing difficulty with
urination.
Answer: Nontunneled central catheter
R: Because therapy will last fewer than 6 weeks,
the patient will most likely receive a nontunneled
central catheter. Peripherally inserted central
catheters are used for intermediate-term (several
days to months) therapy sessions, while tunneled
 C. Tunneled central catheter
D. Nontunneled central catheter
Term
58 / 77
A nurse administered a full strength feeding with
an increased osmolality through a jejunostomy
tube to a client. Immediately following the
feeding, the client expelled a large amount of
liquid brown stool and exhibited a blood pressure
of 86/58 and pulse rate of 112 beats/min. The
nurse
a. Discusses with the nutritionist about
increasing the osmolality of the feeding
b. Increases the amount of feeding at the
next feeding
c. Administers the feeding at a cooler
temperature
d. Consults with the physician about
decreasing the feeding to half-strength
A client is receiving a parenteral nutrition
admixture that contains carbohydrates,
electrolytes, vitamins, trace minerals, and sterile
water and is now scheduled to receive an
intravenous fat emulsion (Intralipid). The nurse
a. Attaches the fat emulsion tubing to a Y
connector close to the infusion site
b. Starts peripheral IV site to administer the
fat emulsion
c. Stops the admixture while the fat
emulsion infuses
d. Connects the tubing for the fat emulsion
above the 1.5 micron filter
When preparing to insert a nasogastric tube, the
nurse determines the length of the tube to be
inserted. The nurse places the distal tip of the
tube at which location?
a. Base of the neck
b. Tip of the patient’s nose
c. Tragus of the ear
catheters and implanted ports are used for long-
term therapy.
Answer: Consults with the physician about
decreasing the feeding to half-strength
R: The osmolality of normal body fluids is 300
mOsm/kg. A feeding with a higher osmolality may
cause dumping syndrome. The client may report
a feeling of fullness, nausea, or both and may
exhibit diarrhea, hypotension, and tachycardia.
The nurse needs to take steps to prevent
dumping syndrome. Increasing the amount of the
feeding, administering the feeding at an extreme
temperature, or increasing the osmolality of the
feedings will continue dumping syndrome. The
nurse needs to decrease the osmolality of the
feeding as in administering a half-strength
solution.
Answer: Attaches the fat emulsion tubing to a Y
connector close to the infusion site
R: An intravenous fat emulsion is attached to a Y
connector close to the infusion site. The fat
emulsion is administered simultaneously with the
parenteral nutrition admixture. A separate
peripheral IV site is not necessary. The fat
emulsion is not administered through a filter.
Answer: Tip of the patient’s nose
R: To measure the length of the nasogastric tube,
the nurse places the distal tip of the tubing at the
tip of the patient’s nose, extends the tube to the
tragus of the ear, and then extends the tube
straight down to the tip of the xiphoid process.
 d. Tip of the xiphoid process
A nurse is preparing to perform a dressing change
to the site of a patient's central venous catheter
used for parenteral nutrition. Which equipment
and supplies would the nurse need to gather?
Select all that apply.
a. Sterile gauze pads
b. Mask
c. Skin antiseptic
d. Clean gloves
e. Extension set tubing
f. Alcohol wipes
A nurse is providing home care to a patient
receiving intermittent tube feedings. The patient
wants to take an over-the-counter allergy
medication. The medication would need to be
given via feeding tube because the patient has
difficulty swallowing. The nurse checks the
medication and finds that it is a timed-release
tablet. Which action by the nurse would be most
appropriate?
a. Have the patient mix it with the feeding
formula after crushing the tablet
b. Check with the pharmacy for an
alternative formulation for the drug
c. State that the patient cannot take the
drug anymore
d. Tell the patient to dissolve the tablet in
water to administer it
Answers:
Sterile gauze pads
Masks
Skin antiseptic
Alcohol wipes
R: When preparing to perform a dressing change
to a central venous access site, sterile technique
is essential. The nurse would need to gather
masks (for self and the patient) to reduce the
possibility of airborne contamination, sterile
gloves, skin antiseptic such as tincture of 2%
iodine or chlorhexadine, sterile gauze to clean
the area, sterile water or saline to clean the area
after cleaning with the skin antiseptic, and
alcohol wipes to clean the catheter ports.
Extension set tubing is not routinely changed
with dressing or tubing changes. Sterile, not
clean, gloves are used.
Answer: Check with the pharmacy for an
alternative formulation of the drug
R: Timed-release medications should not be
crushed. Rather, the nurse should check with the
pharmacy to see if another formulation (eg,
liquid) is available that can be used safely with a
feeding tube. Dissolving the tablet in water, like
crushing it, would affect the drug's action,
possibly releasing too much of the drug too
quickly. Stating that the patient cannot take the
drug anymore is inappropriate. A change in
formulation or possibly a change to another drug
in an appropriate formulation would be
appropriate.
When assessing whether a patient is a candidate
for home parenteral nutrition, which of the
following would be important to address? Select
all that apply.
a. Health status
b. Family support
c. Telephone access
d. Motivation for learning
e. Marital status
Which of the following is the best noninvasive
means of unclogging tubes?
a. Cranberry juice
b. Cola
c. Meat tenderizer
d. Pancreatic enzymes and water
The nurse is inserting a nasoenteric tube for a
patient with a paralytic ileus. How long does the
nurse anticipate the tube will be required?
(Select all that apply.)
a. Until the bowel sound is present
b. Until the tube comes out on its own
c. Until the patient stops vomiting
d. Until peristalsis is resumed
e. Until flatus is passed
Answers:
Health status
Family support
Telephone access
Motivation for learning
R: Ideal candidates for home parenteral nutrition
are patients who have a reasonable life
expectancy after return home, have a limited
number of illnesses other than the one that has
resulted in the need for parenteral nutrition, and
are highly motivated and fairly self-sufficient.
Additional areas to consider include the patient's
ability to learn, availability of family interest and
support, adequate finances, and the physical plan
of the home including access to water, electricity,
refrigeration, and telephone. The patient's
marital status is not important.
Answer: Pancreatic enzymes and water
R: Cola and cranberry juice have historically been
recommended as effective, noninvasive means of
unclogging tubes. Evidence indicates that a
mixture of pancreatic enzymes and water is
superior in restoring the patency of feeding
tubes.
Answers:
Until bowel sound is present
Until peristalsis is resumed
Until flatus is passed
R: Before removing an enteral tube, the nurse
may intermittently clamp it for a trial period of
several hours to ensure that the patient does not
experience nausea, vomiting, or distention.
Before any tube is removed, it is flushed with 10
mL of water or normal saline to ensure that it is
free of debris and away from the gastric lining.
Gloves are worn when removing the tube. The
tube is withdrawn gently and slowly for 15 to 20
cm (6 to 8 in) until the tip reaches the esophagus;
the remainder is withdrawn rapidly from the
nostril. If the tube does not come out easily, force
should not be used, and the problem should be
reported to the primary provider. As the tube is
withdrawn, it is concealed in a towel to prevent
secretions from soiling the patient or nurse. After
the tube is removed, the nurse provides oral

A patient is receiving parenteral nutrition. The
current solution is nearing completion, and a new
solution is to be hung, but it has not arrived from
the pharmacy. Which action by the nurse would
be most appropriate?
a. Have someone go to the pharmacy to
obtain the new solution
b. Slow the current infusion rate so that it
will last until the new solution arrives
c. Hang a solution of dextrose 10% and
water until the new solution is available
d. Begin an infusion of saline in another site
to maintain hydration
A nurse is caring for a patient receiving
parenteral nutrition at home. The patient was
discharged from the acute care facility 4 days
ago. Which of the following would the nurse
include in the patient’s plan of care? SATA.
a. Daily transparent dressing changes
b. Intake and output monitoring
c. Calorie counts for oral nutrients
d. Daily weights
e. Strict bedrest
A patient is receiving continuous tube feedings
via a small bore feeding tube. The nurse irrigates
the tube after administering medication to
maintain patency. Which size syringe would the
nurse use?
a. 30 mL
b. 20 mL
c. 5 mL
d. 10 mL
The nurse inserts a nasogastric tube into the right
nares of a patient. When testing the tube
aspirate for pH to confirm placement, what does
the nurse anticipate the pH will be if placement is
in the lungs?
hygiene.
Answer: Hang a solution of dextrose 10% and
water until the new solution is available
R: The infusion rate of the solution should not be
increased or decreased; if the solution is to run
out, a solution of 10% dextrose and water is used
until the next solution is available. Having
someone go to the pharmacy would be
appropriate, but there is no way to determine if
the person will arrive back before the solution
runs out. Starting another infusion would be
inappropriate. Additionally, the infusion needs to
be maintained through the central venous access
device to maintain patency.
Answers:
Intake and output monitoring
Calorie counts for oral nutrients
Daily weights
R: For the patient receiving parenteral nutrition
at home, the nurse would obtain daily weights
initially, decreasing them to two to three times
per week once the patient is stable. Intake and
output monitoring also is necessary to evaluate
fluid status. Calorie counts of oral nutrients are
used to provide additional information about the
patient's nutritional status. Transparent dressings
are changed weekly. Activity is encouraged based
on the patient's ability to maintain muscle tone.
Strict bedrest is not appropriate.
Answer: 30 mL
R: When small-bore feeding tubes for continuous
tube feedings are used and irrigated after
administration of medications, a 30-mL or larger
syringe is necessary, because the pressure
generated by smaller syringes could rupture the
tube.
Answer: 6
R: Determining the pH of the tube aspirate is a
more accurate method of confirming tube
placement than is maintaining tube length or
 a. 1 visually assessing tube aspirate. The pH method
b. 4 can also be used to monitor the advancement of
c. 6 the tube into the small intestine. The pH of
d. 2 gastric aspirate is acidic (1 to 5), typically less
A client is receiving continuous tube feedings at
75 mL/hr. The nurse has checked the residual
volume 4 hours ago as 250 mL. The nurse now
assesses the residual volume as 325 mL. The first
action of the nurse is to
a. Stop the continuous feeding
b. Discard the residual volume
c. Notify the physician
d. Decrease the rate to 40 mL/hr
A patient has a gastric sump tube attached to low
intermittent suction. The nurse empties the
suction collection chamber and records an output
of 320 mL for this 8-hour shift. The record shows
that the tube had been irrigated with 20 mL of
normal saline twice this shift. What would be the
actual output of the gastric sump tube?
A nurse providing care to a patient who is
receiving nasogastric tube feedings finds that the
tube is clogged. Which of the following would be
least appropriate to use to unclog the tube?
a. Commercial enzyme product
b. Air insufflation
c. Cranberry juice
d. Digestive enzyme mixed with warm
water
A patient is receiving a continuous tube feeding.
The nurse notes that the feeding tube was last
irrigated at 2 p.m. The nurse would plan to
irrigate the tube again at which time?
a. 10 pm to 12am
b. 8pm to 10pm
c. 6pm to 8pm
d. 4pm to 6pm
The nurse is attempting to unclog a patient's
feeding tube. Attempts with warm water
agitation and milking the tube have been
unsuccessful. The nurse uses evidence-based
than 4. The pH of intestinal aspirate is
approximately 6 or higher, and the pH of
respiratory aspirate is more alkaline ( ? 6).
Answer: Notify the physician
R: The second residual volume is greater than the
first. When excessive residual volume (more than
200 mL) of a nasogastric feeding occurs twice, the
nurse notifies the physician. The nurse does not
discard the aspirate because the client has
partially digested this fluid. After discussing with
the physician, the nurse may stop the continuous
feeding for some time or decrease the rate of
infusion.
Answer: 280 mL
R: The output measured includes the two 20 mL
irrigations. To determine the actual output, the
nurse would subtract the amount of irrigation
used (in this case 40 mL total) from the total
output (in this case 320 mL) and arrive at an
output of 280 mL.
Answer: Cranberry juice
R: To unclog a feeding tube, air insufflation,
digestive enzymes mixed with warm water, or a
commercial enzyme product could be used. Cola
and cranberry juice are no longer advocated for
use in clearing a clogged tube.
Answer: 6pm to 8pm
R: The recommendation is to irrigate the feeding
tube of patients receiving continuous tube
feedings every 4 to 6 hours. For this patient, the
nurse would irrigate the tube next at 6 p.m. to 8
p.m.
Answer: Digestive enzymes and sodium
bicarbonate
R: The nurse should attempt to unclog the tube
practice principles when she then uses which of
the following to unclog the tube?
a. Cola mixed with cranberry juice
b. Digestive enzymes and sodium
bicarbonate
c. Alka Seltzer mixed with water
d. Meat tenderizer diluted with saline
After teaching a patient about the procedure for
inserting a nontunneled central catheter, the
nurse determines that the patient has
understood the instructions based on which of
the following statements?
a. “I need to keep my head turned directly
toward you and the physician.”
b. “I will need to take long, slow, deep
breaths when the catheter is inserted.”
c. “I’ll have to wear a thick, bulky dressing
over the site.”
d. “I will be lying on my back but my legs
will be higher than my head.”
A nurse measures the residual gastric volume of a
patient receiving intermittent tube feedings. The
patient's last residual volume was 250 mL. Which
finding would lead the nurse to notify the
physician?
a. 200 mL
b. 225 mL
c. 150 mL
d. 175 mL
with digestive enzymes activated with sodium
bicarbonate. Although historically both cranberry
juice and cola have sometimes been used to
unclog feeding tubes, evidence has shown that
their acidic nature worsens the clog by causing
precipitation of proteins. Meat tenderizer diluted
with saline is not applicable.
Answer: “I will be lying on my back but my legs
will be higher than my head.”
R: For catheter insertion, the patient is in the
Trendelenburg position to produce dilation of the
neck and shoulder vessels, which makes entry
easier and decreases the risk of air embolus. The
patient is instructed to turn the head away from
the site of the venipuncture and to remain
motionless while the catheter is inserted and the
site is dressed. During insertion, until the syringe
is detached from the needle and the catheter is
inserted, the patient may be asked to perform
the Valsalva maneuver, not take long, slow, deep
breaths. Typically, a transparent dressing is
applied over the insertion site.
Answer: 225 mL
R: If a residual volume greater than 200 mL is
obtained twice, the nurse would need to notify
the physician. A single residual volume of 200 mL
or more does not indicate a need to withhold a
feeding. Feedings may be continued in patients
as long as there is close monitoring of gastric
residual volume trends, x-ray study results, and
the patient's physical status.