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Terms in this set (42)Which of the following patients may benefit from enteral nutrition? A. A patient who has a brain injury. Correct A group of nursing students are studying together. They are discussing the differences between parenteral and enteral nutrition. Which
statement, if made by one of the students, indicates further instruction is needed? A. Parenteral nutrition is the administration of nutrients directly into the GI tract by way of a feeding tube." Correct Which of the following accurately describes the greatest risk related to having a
feeding tube? D. Aspiration. Enteral feedings may be administered by: (Select all that apply.) A. Continuous feeding pump. The health care provider has ordered an enteral feeding tube for an elderly patient. Which statement, if made by the patient's family member, indicates further instruction is needed? B. "The tube feedings are used to improve digestion." What determines approximate depth of insertion Measure distance from tip of nose to earlobe to xyphoid process of sternum and mark tube with tape or indelible ink What activates lubricant to facilitate passage of tube into GI tract? Dip tube with surface lubricant into a glass of water What ensures tube patency and aids in guide wire or stylet insertion? Inject 10 mL of water from 30-mL or larger syringe into the feeding tube What closes off glottis and reduces risk of tube entering trachea? Have patient flex head toward chest after tube has passed through nasopharynx What facilitates passage of tube past oropharynx; rotation decreases friction? Have patient mouth breathe and swallow. Give small sips of water or ice chips when possible. Advance tube as patient swallows. Rotate tube 180 degrees while inserting The nurse is inserting an NG feeding tube for the first time. Which action, if made by the nurse, indicates further instruction is needed? A. The nurse dips the end of the tube into a glass of water to activate the lubricant. B. The nurse has the patient flex the head as the tube is inserted into the naris. You have inserted an NG feeding tube. The patient vomited during insertion and continues to gag. What action(s) should you take? (Select all that apply.) A. Suction airway as needed. Correct The health care provider just left the patient's room after explaining the options of NG or NI feeding tube placement. A student asks a nurse about the differences between nasogastric and nasointestinal feedings. Which of the following are accurate statements made by the nurse? (Select all that apply.) A. Insertion of an NG tube requires clean gloves, whereas insertion of an NI tube requires sterile gloves. B. Gastric aspirate is expected to have a lower pH than intestinal aspirate. Correct The patient's wife is watching as the nurse prepares to insert a small bore feeding tube. She asks the nurse, "What is the purpose of the guide wire?" The nurse correctly responds: A. "Because placement must be verified by a chest x-ray, the guide wire is used to determine correct placement when it shows up on radiography." D. "Because feeding tubes are flexible, a guide wire or stylet is used to provide rigidity that facilitates positioning." Correct The patient begins to cough and choke as the nurse is inserting the NG tube. What is the best action for the nurse to take at this time? A. Pull the feeding tube out and start over in the opposite naris. B. Pull the tube back into the posterior nasopharynx and attempt to reinsert. Correct For intestinal placement of a feeding tube, in what position should the nurse place the patient while waiting for radiological confirmation of correct placement? A. On the patient's right side A. On the patient's right side Correct The nurse suspects the patient's feeding tube has migrated. Which of the following would indicate the greatest risk related to tube migration? A. Dyspnea and decreased oxygen saturation. A. Dyspnea and decreased oxygen saturation. Correct
The nurse observes a confused patient pulling at her NG feeding tube. As the nurse retapes the tube to the bridge of the patient's nose, the nurse notices that the mark on the tube has moved away from the naris. What action should the nurse take? A. Advance the tube until the mark is even with the naris and verify correct tube placement. A. Advance the tube until the mark is even with the naris and verify correct tube placement. Correct Identify signs and symptoms of accidental respiratory migration of a feeding tube. (Select all that apply.) A Coughing. Correct Identify the appropriate times to verify enteral tube placement by pH testing. (Select all that apply.) A. Before each intermittent feeding. A. Before each intermittent feeding. Correct Which of the following, if exhibited by the patient, may increase the risk for spontaneous enteral tube dislocation? (Select all that apply.) a. Nausea. c. Vomiting. Correct PH of stomach of fasted person 1-5 PH of Pleural fluid from tracheobronchial tree. 6 or greater PH of Intestine of fasting patient. 6 or greater Sequence the procedure for verifying feeding tube placement. 1. Perform hand hygiene. Apply clean gloves. Draw up 30 mL of air into ENFit syringe, then attach to end of feeding tube. Flush tube with 30 mL of air. 2. Draw back on syringe and obtain 5 to 10 mL of gastric aspirate. Observe appearance of aspirate. 3. Measure pH of aspirate. Compare the color of the strip with the color on the chart provided by the manufacturer. 4. Discard used supplies, remove gloves and discard, and perform hand hygiene. The nurses are discussing feeding tube migration and prevention. Which of the following statements indicates correct understanding? B. A feeding tube can enter the airway without causing obvious respiratory symptoms. Correct If the nurse suspects the NG feeding tube has migrated, the nurse should: Stop any enteral feedings and obtain an order for a chest x-ray film to determine placement. The nurse aspirates stomach contents from a newly inserted feeding tube. The nurse is aware the patient has been on the proton pump inhibitor omeprazole. The pH strip reads "3." Where should the nurse expect the x-ray film to identify placement of the feeding tube? C. In the stomach. Correct The nurse understands that irrigating a feeding tube helps prevent it from becoming clogged and clears the tubing of fluid. At what times is it appropriate to flush a feeding tube? (Select all that apply.) B. Before medication administration. The nurse is going to irrigate a nasogastric feeding tube. The nurse would be correct to draw up how much water into the ENFit syringe? B. 30 mL. Correct A nursing instructor is reviewing the skill of irrigating a feeding tube with a group of nursing students. Which statement(s), if made by the nursing student, is(are) accurate, indicating learning has occurred? (Select all that apply.) A. "Curdled enteral formula and improperly crushed medications are the most common causes of feeding tube occlusion." Correct A nurse is reviewing the policy for irrigating
a feeding tube. What information should the nurse include that would address accurate principles of infection control when performing this procedure? (Select all that apply.) A. Change irrigation bottle every 24 hours. Correct The nurse is irrigating a nasogastric feeding tube after having verified tube placement by pH testing. The nurse draws up 30 mL of tap water into an ENFit syringe, removes the plug at the end of the tube, attaches the ENFit syringe, and slowly instills the irrigation solution. The nurse removes the syringe and plugs the end of the tube. What error occurred in the performance of this skill? A. There was no error; the nurse performed the skill correctly. b. The nurse failed to kink the tubing before connecting and removing the syringe from the end of the feeding tube. Correct A nurse is telling a coworker that she is unable to flush a feeding tube. Which suggestion offered by the coworker would be accurate, useful information? A. Try using Coca-Cola to flush the tubing; the carbonation will break up any blockage." D. "Reposition the patient and see if you are able to flush the tubing with water." Why is it important to have the tube feeding at room temperature? Cold formula can cause gastric cramping. The nurse is going to irrigate the patient's established feeding tube with 30 mL of tap water before instilling the tube feeding. The nurse attempts to do so without success. What should action should the nurse take? Reposition the patient. ***The nurse should first reposition the patient on the left side and try again. The tip of the tube may be lying against the stomach wall. Changing the patient's position may move the tip away from the stomach wall. The nurse may attempt to flush the tubing with a large-bore syringe and warm water. If still unable to clear the feeding tube, the health care provider should be notified. Baking soda or cola should never be used because they could cause further complications if aspirated. The patient is presently receiving intermittent tube feedings of 120 mL every 6 hours. The health care provider's orders state: Jevity formula feeding 240 mL every 6 hours per feeding tube, increase per patient tolerance. Which of the following assessment data indicate patient intolerance of the tube feeding and therefore inability of the rate to be increased? (Select all that apply.) A. Diarrhea. A. Diarrhea. Correct A patient is receiving a continuous enteral feeding by infusion pump. The nurse enters the patient's room to verify tube placement and measure residual. The nurse notices the patient's respirations are shallow and rapid and that the patient's color is ashen. The nurse notes crackles on auscultation, and the patient appears to be coughing up sputum of a color similar to the formula feeding. What action(s) should the nurse take? (Select all that apply.) B. Position patient on side. Correct ***The patient has aspirated formula. The nurse should turn off the tube feeding immediately, position the patient in in a side-lying position, suction, and notify the health care provider. It is unnecessary to ask the patient about feeling short of breath because it is apparent. Having the patient deep breathe and cough will fail to help at this time. Which of the following is an appropriate nursing action to prevent a complication of nasogastric (NG) tube feedings? Keep the head of the patient's bed elevated at least 30 degrees. ***Head of bed elevation to a minimum of 30 degrees is a simple method to keep the risk for aspiration at a minimum. The nurse is instrumental in achieving this goal. To prevent air from entering stomach between feedings, clamp or plug end of tube when feeding is absent. The nurse should refill the syringe before it is completely empty until prescribed amount has been administered. Use a new administration set every 24 hours for an open system. The nurse is going to administer a bolus enteral tube feeding of 240 mL. The nurse has obtained a pH of 4 and 50 mL of gastric aspirate. Based on these findings, what action should the nurse take? Return the aspirate to the patient's stomach and administer the feeding. ***These are normal findings. The nurse should return the gastric aspirate to the patient's stomach to prevent an alteration in electrolyte balance and administer the tube feeding as prescribed. The patient is receiving a continuous enteral feeding. Which of the following assessment findings would require follow-up? Gastric residual of 375 mL. ***GRVs in range of 200 to 500 mL should raise concern and lead to implementation of measures to reduce risk of aspiration. Normal residual for a nasoenteric tube is in the 10 mL or less range. Bowel sounds in all four quadrants and pH of 5.0 in gastric contents is normal for a patient who is receiving continuous enteral feeding. The nurse is going to administer an intermittent tube feeding. Because the patient's feeding tube has been in place for 3 days, which action is best for the nurse to take at this time? Aspirate gastric contents and test on a pH strip. ****Ongoing verification of tube placement is made by pH testing of aspirate. Verification by x-ray film is necessary on feeding tube insertion and if tube migration is suspected. Auscultation is no longer considered a reliable method for determining feeding tube placement. The tube can migrate without moving at its externally taped location. 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This nurse was fired because the nurse has: 4 answers QUESTION What are the stages of sedation? 10 answers Which action is used to check the placement of a feeding tube before administering feeding?Correct placement of the tube should be confirmed prior to administration of an enteral feed by checking insertion site at the abdominal wall and observing the child for abdominal pain or discomfort.
Which nursing action is appropriate when providing care to a patient who is prescribed intermittent tube feedings quizlet?The appropriate nursing action when providing care to a patient who is prescribed intermittent tube feedings is to check tube placement prior to each feeding.
What is used for the feeding if it is being given intermittently?Intermittent feeding is administered via an electric enteral feeding pump or gravity drip.
How do you do intermittent enteral feeding?Intermittent enteral feeding (IEF) is defined by administration of bouts lasting 20–60 min, 3-to-6 times per day. When bouts of feeding last 4–10 min and are administered by syringe or gravity drip, the appropriate definition is bolus feeding.
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