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Terms in this set (31)
Which nursing action is appropriate prior to administering a nasoenteric feeding?
Assessing capillary blood glucose
Prior to implementing a nasogastric feeding, the nurse should monitor laboratory values, including electrolytes and capillary blood glucose levels. These values provide a baseline to measure the patient's response to enteral nutrition
How often should the nurse change the feeding bag for a patient who is prescribed an intermittent enteral feeding?
Every day
Which nursing action is appropriate when planning to intubate a patient with a prescribed feeding tube?
Explaining the sensations that are expected
In which position should the nurse place the patient to conduct blood glucose monitoring?
Semi-Fowler's
Which equipment should the nurse have available when assessing the pH of gastric aspirate?
Test paper
Which are the rights the nurse should implement to enhance safety for a patient who is prescribed enteral feedings? Select all that apply.
Tube
Patient
Formula
ENFit adapter
Which equipment should the nurse have available when testing a patient's blood glucose level? Select all that apply.
When testing a patient's blood glucose level, the nurse should have a lancet, paper towel, and antiseptic swab available.
Which assessment finding should the nurse report to the health care provider for a patient who is prescribed aspiration precautions? Select all that apply.
aspiration precautions include choking, gagging, coughing, and difficulty swallowing. All of these findings could indicate the patient has aspirated.
The nurse is providing care to a patient who has reached the maximum administration rate for the prescribed enteral feedings. How often should the nurse weigh the patient based on the current data?
Three times per week
Which complication may occur if the nurse were to add food coloring to the formula for a patient who is prescribed enteral feeding?
Food coloring is not added to the formula used when administering a prescribed enteral feeding because this can cause hypotension.
Which information should the nurse include on the label of an enteral feeding to promote patient safety? Select all that apply.
The nurse should include the date and time the formula is hung, the patient's name, the rate of the feeding, and the patient's room number on the label to promote the safety of a patient who is prescribed enteral feedings.
Which nursing action is appropriate for a patient with a gastric aspirate of 150 mL?
Return all the aspirate
When assessing a patient prior to insertion of an enteral feeding tube, which finding should alert the nurse to poor nutrition?
An enlarged spleen may indicate the patient has poor nutrition during the assessment prior to the insertion of an enteral feeding tube.
Which data should nurse document in the patient's medical record after the intubation of an enteral tube? Select all that apply.
the type and size of tube inserted, the pH value of the gastric aspirate, and confirmation of tube placement by x-ray film. The location of the distal, NOT PROXIMAL, end of the tube should also be documented.
Which nursing action is inappropriate when checking for gastric residual volume (GRV) before each enteral feeding?
The inappropriate nursing action is to discard the gastric contents. This action could lead to fluid and electrolyte imbalances and should be avoided. Flushing the tube with 30 mL of air, administering the feeding for a gastric volume of 425 mL, and pulling back slowly to aspirate the total volume of gastric contents are all appropriate nursing actions.
Until radiographic confirmation of placement of an intestinal tube is completed, in which position should the nurse place the patient after intubation?
Side-lying
Which are possible causes for constipation in a patient who is prescribed enteral tube feedings? Select all that apply.
Causes of constipation for a patient who is prescribed enteral tube feedings include inactivity and lack of fiber in the diet. Malabsorption, too much free water, and bacterial contamination may cause diarrhea, not constipation, in a patient who is prescribed enteral tube feedings.
Which assessments should the nurse perform prior to inserting a nasoenteric tube for enteral feedings? Select all that apply.
Height
Weight
Hydration status
This information provides baseline information to measure nutritional improvement after enteral feedings are initiated.
Which piece of equipment should the nurse have available to remove a small-bore nasoenteric tube for a patient whose enteral feedings have been discontinued?
Oral hygiene supplies
Which nursing action is appropriate when providing care to a patient who is prescribed aspiration precautions and is experiencing weight loss?
Consult with the patient's dietician
Which nursing action is appropriate when providing care to a patient whose enteral feeding tube is clogged?
Using pancreatic enzymes
Which nursing action is appropriate when providing care to a patient who experiences pulmonary aspiration due to enteral feedings?
Suctioning the airway
Which patient behaviors should the nurse instruct nursing assistive personnel (NAP) to report during the administration of an enteral feeding? Select all that apply.
During an enteral feeding, the nurse should instruct nursing assistive personnel (NAP) to report choking, gagging, and coughing, because these may indicate that the patient has aspirated.
Which pieces of equipment should the nurse have available to intubate a patient with a feeding tube? Select all that apply.
The nurse should have a towel, stethoscope, and water-soluble lubricant available during the insertion, or intubation, of a feeding tube.
Which nursing actions are appropriate when obtaining gastrointestinal (GI) aspirate for pH measurement in a patient who is prescribed continuous tube feedings? Select all that apply.
Drawing 30 mL of air into the syringe
Planning the test after chest physiotherapy
Checking tube placement every 4 to 6 hours
Which is the priority nursing action when intubating a patient with a feeding tube?
Verifying the health care provider's order
How often should the nurse check gastric residuals for patients who are prescribed aspiration precautions?
Every 4 hours
Which nursing actions are appropriate when checking for gastric residual volume (GRV) before each enteral feeding? Select all that apply.
Flushing the tube with 30 mL of water
Holding the feeding for an aspirate volume of 525 mL
Pulling back slowly to aspirate total volume of gastric contents
Which nursing action is appropriate when providing care to a patient who is prescribed intermittent tube feedings?
Checking tube placement prior to each feeding
Which data should the nurse document in the medical record when providing care to a patient who is receiving enteral tube feedings? Select all that apply.
Patency of the tube
Amount and type of tube feeding
Condition of the skin at the site of the tube
Which statement by the nurse exemplifies the Teach Back method to determine patient and family understanding regarding dysphagia?
"I want to be sure I properly explained dysphagia and how to prevent choking. Can you explain to me why these steps protect you from choking?"
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