Open Resources for Nursing (Open RN) Show Sample Documentation of Expected FindingsTube FeedingPatient’s abdomen is soft, nondistended, and bowel sounds are present in all four quadrants. Head of the bed elevated to 45 degrees. Placement of tube verified with measurement of the tube at the nares at 55 cm and gastric aspirate had a pH 4. Patient tolerated 240 mL of tube feeding by gravity followed by a 30-mL water flush. Tube IrrigationIrrigated NG tube with 30 mL of water with no resistance. Patient tolerated flush without symptoms. Tube SuctioningNG tube connected to low-intermittent suction (LIS) at 60 mmHg. Output from the NGT is green with a volume of 100 mLs in eight hours. Sample Documentation of Unexpected FindingsTube FeedingPatient’s abdomen is soft, nondistended, and bowel sounds are present in all four quadrants. Head of the bed elevated to 45 degrees. Placement of tube verified with measurements of tube at nares at 55 cm and gastric aspirate with a pH of 4. After 100 mLs of tube feeding was infused, the patient complained of feeling full and nauseated. Tube feeding infusion stopped and the head of the bed maintained at a 45-degree angle. Will reassess gastric volume residual in one hour and determine if tube feeding will be resumed. Tube IrrigationAttempted to irrigate NG tube with 30 mLs of water, but resistance was felt with procedure. Unable to inject water flush into the NGT. Dr. Smith notified of findings at 1320. Tube SuctioningPatient’s abdomen is slightly distended and bowel sounds are hypoactive in all four quadrants. Patient reports increased nausea over the last two hours. NGT connected to low-intermittent suction (LIS) at 60 mmHg. Output from the NGT is mahogany colored with a volume of 800 mLs in eight hours. Dr. Smith notified of findings at 1640. A nurse is collecting data about a client’s respiratory system. Which of thefollowing breath sounds should the nurse expect to hear over the peripheryof the major lung fields? Get answer to your question and much more A nurse employs a thorough, systematic method for obtaining OBJECTIVEdata about a client. Which of the following methods should the nurse us tocollect this information? Get answer to your question and much more A nurse is assisting a provider with performing thoracentesis to removepleural fluid. How should the nurse position the client? Get answer to your question and much more A nurse is preparing to insert an NG tube for a client who requires enteralfeedings. Which of the following instructions should the nurse give the clientbefore beginning the procedure? Get answer to your question and much more A nurse is performing a mental-status exam for a client who hasmanifestations of dementia. Which of the following directions should thenurse give the client when evaluating the client’s ability to think abstractly? Get answer to your question and much more A nurse is presenting an in-service session about nutrition. Which of thefollowing simple sugars should the nurse identify as the carb found in milk? Get answer to your question and much more A nurse is assisting with teaching a newly licensed nurse about painmanagement in clients age of 65 and older. Which of the following pieces ofinformation should the nurse include? Get answer to your question and much more A nurse in an oncology clinic is collecting data for a client who is undergoingtreatment for ovarian cancer. Which of the following statements by the clientindicate she is experiencing psychological distress? Get answer to your question and much more A nurse is assisting with the admission of a client to the medical unit andasks if he has advance directives. The client states “I have a document withme that names someone who can make health care decisions for me if i amnot able.” The nurse should identify that the client is referring to which of the Get answer to your question and much more |
A nurse is collecting data from a client who has an NG tube set to low intermittent suction
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