Enteral Nurtrition post test 5 PDF

Preview

Summary

The study material for enteral nutrition post-test....

Description

1. 1.ID: 18668362601 Why is it important to have the tube feeding at room temperature? A. B. C.

It is unnecessary to keep the tube feeding cold because it will be hanging at room temperature anyway. It aids the speed of digestion. Cold formula can cause gastric cramping. Correct Cold formula can cause gastric cramping.

D. Cold formula may lower the patient's body temperature. Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 18668362607 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? A.

Notify the health care provider.

B.

Irrigate the tubing with soda, such as Coca-Cola.

C.

Reposition the patient. Correct 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.

D.

Use a smaller syringe with the plunger to push the fluid through the feeding tube. Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 18668362605 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. Correct

B.

Abdominal distention and discomfort. Correct

C.

Nausea. Correct

D.

Flatulence.

E.

Thirst.

F.

Residual volume greater than 500 mL. Correct

If the patient develops diarrhea 3 or more times in 24 hours, this indicates intolerance. Notify the health care provider and confer with the dietitian to determine the need to modify the type of formula, concentration, or rate of infusion. Tolerance is indicated by absence of nausea and diarrhea and by low gastric residuals. Residual volume indicates whether gastric emptying is delayed; 500 mL or more remaining in the patient's stomach may reflect delayed gastric emptying. Abdominal discomfort and distention may indicate intolerance to the tube feeding, possibly from too rapid an infusion. Flatulence and thirst do not indicate an intolerance to tube feeding. Awarded 4.0 points out of 4.0 possible points. 4. 4.ID: 18668362603 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.) A.

Ask if the patient feels short of breath.

B.

Position patient on side. Correct

C.

Turn off the tube feeding. Correct

D.

Have the patient deep breathe and cough.

E.

Suction the patient. Correct

F. Notify the health care provider. 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. Awarded 4.0 points out of 4.0 possible points. 5. 5.ID: 18668362611 Which of the following is an appropriate nursing action to prevent a complication of nasogastric (NG) tube feedings? A.

Keep the head of the patient’s bed elevated at least 30 degrees. Correct 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.

B.

Leave the feeding tube unclamped and unplugged between feedings.

C.

Allow the syringe to empty of feeding before adding more to the syringe.

D.

Change the feeding tube bag and tubing every 72 hours for a continuous feeding. Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 18668362609 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? A.

Stop the feeding and recheck the residual in 1 hour.

B.

Reposition the feeding tube under fluoroscopy.

C.

Discard the aspirate and continue with the bolus feeding as prescribed.

D.

Return the aspirate to the patient’s stomach and administer the feeding. Correct 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. Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 18668362613 The patient is receiving a continuous enteral feeding. Which of the following assessment findings would require follow-up? A.

Gastric residual of 375 mL. Correct 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.

B.

Bowel sounds present in all four quadrants.

C.

pH of gastric contents 5.0.

D. Less than 10 mL of aspirate from nasoenteric tube. Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 18668362399 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? A.

Obtain an order for x-ray film verification of tube location.

B.

Auscultate over the gastric area while instilling 30 mL of air into the feeding tube.

C.

Aspirate gastric contents and test on a pH strip. Correct 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. D. Verify the indelible ink mark on the tube is at the nares. Awarded 1.0 points out of 1.0 possible points....