Complex 2 Exam 3 2025. 84 Questions And Answers

Complex 2 Exam 3
Enteral nursing assessment *** Assessments q 4 hr:

· asses patency Q4: flush with water before/after feedings if not on continuous fluids to loosen any
excess that may clog up tubes

· Assess shape & feel of abdomen (assess for tenderness upon palpation)

· Abdominal x-ray before initial feeding

· Auscultate bowel sounds (all bowel quadrants)

· Stability of tube: look at marker outside of tube

· Monitor I/O & daily weight

· Glucose checks first 24 hr typically q 4-6hrs



Enteral complications *** Dumping syndrome

- Results from emptying of formula too quickly into small intestine, which causes a fluid shift

- May manifest as dizziness, tachycardia, diaphoresis, pallor

Metabolic issues: dehydration, hyperglycemia, electrolyte imbalance, fluid overload, refeeding
syndrome, weight gain

- Provide adequate free water (balance between dehydration & overload), consider change in formula,
monitor labs (electrolyte, glucose), monitor weight, Tx hyperglycemia with insulin

Overfeeding

- N/V, abdominal distention

- Check residual Q4-6

- Hold for residual volumes of 100-200mL then restart at a lower rate

- Ensure the feeding pump is working right

Diarrhea

- D/t concentration of feeding

- Slow the rate & notify provider

,- Provide skin care and increase fiber

- Evaluate for C.Diff if diarrhea continues especially if very foul odor



Enteral complications continued.. *** Aspiration pneumonia - Tube displacement - LIFE THREATENING

- STOP the feeding

- Turn pt to one side, suction airway, provide O2

- Monitor VS for elevated temp

- Auscultate breath sounds

- Notify provider & obtain chest x-ray

Refeeding syndrome - LIFE THREATENING

- When pt is in a starvation state & given enteral feeding, body begins to catabolize protein & fat for
energy

- Monitor for new onset of confusion, seizures, & increased muscular weakness

- Assess for shallow respirations

- Notify provider & obtain blood electrolytes



Enteral nursing interventions *** - Check patency q 4 hrs and before and after use of tube for feeding

- if you need to lay pt down turn feeding off

- HOB at least 30-45 once resumed feeding and up to at least 1 hr after feeding

- Check placement q shift

Aspirate and test the pH of stomach contents

- pH < 4 = tube is in the stomach (gastrostomy tube)

- pH > 6 = tube is in the jejunum (jejunostomy tube)

- Residual checks for NG tubes

,Parenteral composition *** · Amino acids (protein) & glucose (dextrose) make up the base solution
(along with sterile water)

· Electrolytes, minerals, vitamins, & trace elements are added according to client needs

· Lipids (fats) may be added to the solution OR given as a separate intermittent infusion



Parenteral prioritization *** · Always admin via infusion pump to prevent accidental fluid overload NOT
GRAVITY

· TPN must have a filter in tubing to collect particles from solution

· Gradually adjust the flow rate to allow the body to adjust & then keep it consistent (increasing the rate
can lead to overload or hyperosmolar diuresis)

· Monitor BUN

· NEVER abruptly stop TPN --> D/C gradually to prevent rebound hypoglycemia

· CANNOT change the rate after reaching the target rate

- If TPN solution is not available: admin dextrose in water until TPN can be resumed (maybe
D10W...10%-20% dextrose)



Parenteral nursing interventions/complications *** 1. Infection/sepsis: may be a result of contamination
during catheter insertion or contamination solution (high concentration of dextrose=fuel for bacteria)

- Change CVL dressing using sterile technique q 48-72

- Monitor for S/Sx of infection (fever/chills, elevated WBC, redness at cath insertion site)

- Change solution bag & IV tubing Q24

- DO NOT USE TPN LINE FOR OTHER IV BOLUS FLUIDS/MEDS)

- observe the central insertion for local infection (erythema, exudate, tenderness)

2. Hyperglycemia(durin feeding) hypoglycemia(in btwn feeding), electrolyte/vitamin imbalance

- Monitor glucose & admin sliding scale insulin to treat hyperglycemia

- Review Daily labs & get results BEFORE NEW TPN is made (nsulin may be added to the solution by
pharmacy)

- Admin additional dextrose to treat hypoglycemia

, 3. Catheter misplacement leading to pneumo/hemothorax, thrombosis, air embolism

- Monitor for S/Sx of air embolus (sudden respiratory distress, decreased O2 sat, SOB, cough, chest pain,
hypotension)

- Clamp catheter & lay on L side in Trendelenburg to trap air in RA - Admin high flow O2 - Notify provider

4. Fluid overload: TPN is hyperosmotic which can cause FVE

- Monitor daily weight & I/O

-assess lung sounds for crackles

- gradually increase flow rate



Acute abdominal pain: how do all of the below issues manifest in the patient? *** · Appendicitis: RLQ
pain, dull pain around naval area

· Pancreatitis: epigastric pain radiating to back, left flank, or left shoulder pain

· Perforation: severe pain all over abdomen

· Diverticulitis: LLQ pain

· Cholycystitis/Cholelithiasis: RUQ pain radiating to R shoulder



Acute abdominal pain: know the specific clinical manifestations for each disease process *** RUQ

• Liver - Hepatitis

Transplant rejection:

• Duodenal ulcer

• Cholecystitis

RLQ

• Appendicitis

• Crohn's disease

LUQ

• Gastric ulcer