3101 Skills: chap. 45 Nutrition

Every day Rationale The feeding bag that is used to administer intermittent enteral feedings is changed every 24 hours or daily. Changing the bag every 8 hours and every 12 hours is more often than necessary. The feeding bag should be changed more frequently than every other day. p. 1092

How often should the nurse change the feeding bag for a patient who is prescribed an intermittent enteral feeding? Every day Every 8 hours Every 12 hours Every other day

Metoclopramide Rationale Metoclopramide, a prokinetic agent, may be prescribed prior to the intubation of a nasointestinal (NI) tune to help advance the tube into the intestine. Morphine, apriprazole, and acetaminophen have other purposes and are not used prior to NI intubation. p. 1086

Which medication prescription would the nurse expect to see in the medical record prior to intubating a patient with a nasointestinal (NI) tube? Morphine Aripiprazole Acetaminophen Metoclopramide

Enlarged spleen Rationale An enlarged spleen may indicate the patient has poor nutrition during the assessment prior to the insertion of an enteral feeding tube. Moist lips, shiny hair, and a smooth tongue all indicate good nutrition. p. 1067

When assessing a patient prior to insertion of an enteral feeding tube, which finding should alert the nurse to poor nutrition? Moist lips Shiny hair Smooth tongue Enlarged spleen

Adding an additional 20 to 30 cm (8 to 12 in) to the measured length of the tube Rationale To determine the length of the tube needed for a nasointestinal (NI) intubation, the nurse should add an additional 20 to 30 cm (8 to 12 in) to the measured length of the tube. Subtracting anything from the measured length and adding an 10 to 20 cm (4 to 8 in) will result in an inaccurate length. p. 1086

How can the nurse determine the length of the tube needed for a nasointestinal (NI) intubation? Subtracting 10 to 20 cm (4 to 8 in) to the measured length of the tube Subtracting 20 to 30 cm (8 to 12 in) to the measured length of the tube Adding an additional 20 to 30 cm (8 to 12 in) to the measured length of the tube Adding an additional 10 to 20 cm (4 to 8 in) to the measured length of the tube

Placing the patient in reverse Trendelenburg's position Rationale When administering an enteral feeding to a patient who must remain supine, the nurse should place the patient in reverse Trendelenburg's position; keeping the patient's head elevated helps prevent aspiration. The Sim's, lithotomy, and high-Fowler's positions will not allow the patient to remain supine. p. 1091

The nurse is administering an enteral feeding to a patient who must remain in a supine position. Which nursing action is appropriate? Placing the patient in Sim's position Placing the patient in a lithotomy position Placing the patient in high-Fowler's position Placing the patient in reverse Trendelenburg's position

Towel Stethoscope Water-soluble lubricant Rationale The nurse should have a towel, stethoscope, and water-soluble lubricant available during the insertion, or intubation, of a feeding tube. A tuning fork and reflex hammer are required for other procedures. p. 1085

Which pieces of equipment should the nurse have available to intubate a patient with a feeding tube? Select all that apply. Towel Tuning fork Stethoscope Reflex hammer Water-soluble lubricant

Identifying the patient using two identifiers Rationale Identifying the patient using two identifiers (such as the patient's name and birthday or name and medical record) is a nursing action that complies with the Joint Commission standards and promotes patient safety when administering an enteral feeding by a nasoenteric tube. It should be done first to limit mistakes of identification. The remaining actions promote safety as well but can be done following identification. Explaining the procedure to the patient enhances cooperation and places the patient at ease. Checking the expiration date on the patient's formula reduces the patient's risk for feeding-borne gastrointestinal infections. Performing hand hygiene reduces transmission of microorganisms. p. 1090

Which priority nursing action complies with the Joint Commission standards and promotes patient safety when administering an enteral feeding by a nasoenteric tube? Explaining the procedure to the patient Identifying the patient using two identifiers Checking the expiration date on the patient's formula Performing hand hygiene prior to touching the patient

Every 4 hours Rationale Gastric residuals should be monitored every 4 hours for patients who are prescribed aspiration precautions. For patients who are prescribed aspiration precautions, every 2 hours is too frequent, and every 6 or 8 hours is not enough. p. 1078

How often should the nurse check gastric residuals for patients who are prescribed aspiration precautions? Every 2 hours Every 4 hours Every 6 hours Every 8 hours

Semi-Fowler's Rationale The nurse should place the patient in a semi-Fowler's position when conducting blood glucose monitoring. The prone, side-lying, and Trendelenburg's positions are patient positions for other procedures. p. 1095

In which position should the nurse place the patient to conduct blood glucose monitoring? Prone Side-lying Semi-Fowler's Trendelenburg's

It reduces sepsis. It decreases hospital mortality. It maintains intestinal structure and function. Rationale Early introduction of enteral feeding decreases the risk of sepsis by preventing the shift of the microorganisms from the lumen to the cells. It decreases hospital mortality by decreasing complications. It maintains the intestinal structure and function by protecting it from gastric enzymes. Enteral feeding minimizes the hypermetabolic response of trauma by providing adequate nutrition and calories. Enteral feeding increases the risk of aspiration pneumonia due to the placement of a nasogastric tube. p. 1075

The nurse is caring for a patient who is on enteral feeding. What are the advantages of enteral feeding? Select all that apply. It reduces sepsis. It decreases hospital mortality. It maintains intestinal structure and function. It maximizes the hypermetabolic response to trauma. It decreases the risk of aspiration.

Supine Rationale The patient should not be placed in a supine position, because the risk of aspiration is high. To prevent aspiration, the patient should be made to sit in a chair or in a Fowler's position. This position helps the patient to swallow properly and prevents the risk of food going into the airway. The chin-tucked position helps to prevent aspiration. Test-Taking Tip: Answer every question because on the NCLEX ® exam, you must answer a question before you can move on to the next question. p. 1074

The nurse is feeding a patient with dysphagia. Which position of the patient should be avoided to reduce the risk of aspiration? Supine Sitting in a chair High Fowler's position Chin-tucked position

Rechecking the GRV in 1 hour Rationale The priority nursing action in this situation is to hold the feeding and recheck the gastric residual volume (GRV) in 1 hour. The nurse should consult with the patient's health care provider, not the dietician, in this situation. The patient should be placed in an upright position, not a side-lying position. The GRV should be returned and the feeding held; discarding the GRV can cause fluid and electrolyte imbalances. pp. 1092, 1094

The nurse is providing care to a patient who is prescribed intermittent enteral feedings. Prior to the scheduled feeding, the nurse notes a gastric residual volume (GRV) of 260 mL. Which nursing action is the priority? Rechecking the GRV in 1 hour Consulting with the patient's dietician Placing the patient in a side-lying position Discarding the GRV and administering the scheduled feeding

Side-lying Rationale The patient should be placed in a right side-lying position after intubation of an intestinal tube until radiographic confirmation takes place because this positioning promotes passage of the tube into the small intestine. The prone, supine, and lithotomy positions are less facilitative of this passage. p. 1088

Until radiographic confirmation of placement of an intestinal tube is completed, in which position should the nurse place the patient after intubation? Prone Supine Side-lying Lithotomy

Telling the patient to open his or her mouth Encouraging the patient to feel the food in his or her mouth Asking the patient to cough in order to clear the airway Teaching the patient to raise his or her tongue to the roof of the mouth when eating Rationale Nursing actions that are appropriate when feeding a patient who is prescribed aspiration precautions include: telling the patient to open his or her mouth; encouraging the patient to feel the food in his or her mouth; asking the patient to cough in order to clear the airway; and teaching the patient to raise the tongue to the roof of the mouth when eating. The nurse should provide more time and rest periods as needed rather than rushing the patient through a meal. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 1084

Which actions should the nurse implement when feeding a patient who is prescribed aspiration precautions? Select all that apply. Telling the patient to open his or her mouth Encouraging the patient to feel the food in his or her mouth Asking the patient to cough in order to clear the airway Rushing the patient to finish the meal as soon as possible Teaching the patient to raise his or her tongue to the roof of the mouth when eating

Tube Patient Formula ENFit adapter Rationale The rights the nurse should implement to enhance safety for a patient who is prescribed enteral feedings includes the right tube, patient, formula, and ENFit adaptor. The right dose, not enteral tube feeding administration, is a right of medication administration. p. 1082

Which are the rights the nurse should implement to enhance safety for a patient who is prescribed enteral feedings? Select all that apply. Dose Tube Patient Formula ENFit adapter

Choking Gagging Coughing Difficulty swallowing Rationale Assessment data that requires notification to the health care provider when caring for a patient prescribed aspiration precautions include choking, gagging, coughing, and difficulty swallowing. All of these findings could indicate the patient has aspirated. Difficulty passing flatus may be a finding the nurse would report to the health care provider for another issue but not for aspiration concerns. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 1083

Which assessment finding should the nurse report to the health care provider for a patient who is prescribed aspiration precautions? Select all that apply. Choking Gagging Coughing Difficulty swallowing Difficulty passing flatus

Type of tube Size of the tube pH value of gastric aspirate Confirmation of tube placement by x-ray film Rationale After the patient is intubated with an enteral tube the nurse documents 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. p. 1089

Which data should nurse document in the patient's medical record after the intubation of an enteral tube? Select all that apply Type of tube Size of the tube pH value of gastric aspirate Location of the proximal end of the tube Confirmation of tube placement by x-ray film

Patency of the tube Amount and type of tube feeding Condition of the skin at the site of the tube Rationale The nurse should document the patency of the patient's tube, the amount and type of tube feeding, and the condition of the patient's skin at the site of the tube. The goal weight and most recent vital signs are not included in the documentation for this patient. p. 1094

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. Goal weight Patency of the tube Most recent vital signs Amount and type of tube feeding Condition of the skin at the site of the tube

Test paper Rationale The nurse should have test paper available when assessing the pH of gastric aspirate. Other equipment the nurse should have available includes paper, not cloth, towels; clean, not sterile, gloves; and a small, not large, medication cup. p. 1077

Which equipment should the nurse have available when assessing the pH of gastric aspirate? Test paper Cloth towel Sterile gloves Large medication cup

Watery stool over the last day An excessively snug external disk Redness and irritation at the insertion site Rationale Data that would necessitate further action by the nurse when providing care to a patient who is receiving enteric feeding with a gastrostomy tube inserted through the abdominal wall include watery stool, an excessively snug external disk, and redness and irritation at the insertion site. Watery stool often indicates the rate of the feeding is too fast. A disk that is too snug may cause skin breakdown. Redness and irritation at the insertion site can increase the risk for skin breakdown and infection. Active bowel sounds in all quadrants and lack of aspirate are normal findings that do not require interventions. p. 1090

Which findings would necessitate further intervention by the nurse when caring for a patient with a gastrostomy tube inserted through the abdominal wall? Select all that apply. Watery stool over the last day An excessively snug external disk Active bowel sounds in all quadrants Lack of aspirate noted prior to feedings Redness and irritation at the insertion site

Date and time Patient's name Rate of feeding Patient's room number Rationale 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. The patient's medical record number is not necessary for patient safety. p. 1082

Which information should the nurse include on the label of an enteral feeding to promote patient safety? Select all that apply. Date and time Patient's name Rate of feeding Patient's room number Patient's medical record number

Performing hand hygiene Rationale The first nursing action when monitoring a patient's blood glucose level is to perform hand hygiene. Hand hygiene limits the transfer of microorganisms. While turning on the glucometer, choosing the puncture site, and removing the reagent strip from the container are all appropriate nursing actions for this procedure, these will not be the first step for the nurse. Test-Taking Tip: Key words or phrases in the question stem such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. No real absolutes exist in life; however, every rule has its exceptions, so answer with care. pp. 1095-1096

Which is the first nursing action when monitoring a patient's blood glucose level? Performing hand hygiene Turning on the glucometer Choosing the puncture site Removing the reagent strip from container

Inspecting the patient's naris for irritation Rationale The priority nursing action when evaluating the patient after the insertion of an enteral feeding tube is to inspect the patient's naris and oropharynx for irritation. This irritation is most likely to occur if the intubation was difficult. Assessing the patient's comfort, auscultating the patient's lung sounds, and confirming the patient's x-ray film results are all nursing actions that should come after examining the patient for irritation. p. 1089

Which is the priority nursing action when evaluating the patient after the insertion of an enteral feeding tube? Assessing the patient's comfort Auscultating the patient's lung sounds Confirming the patient's x-ray film results Inspecting the patient's naris for irritation

Verifying the health care provider's order Rationale The priority nursing action when intubating a patient with a feeding tube is to verify the health care provider's order; this is the first requirement for implementing any procedure. Clean, not sterile, gloves are needed when performing this procedure. The nurse should determine the patient's knowledge of the procedure and review the medical record for history of nasal problems; however, these actions are performed after verifying the provider's order for the feeding tube. p. 1085

Which is the priority nursing action when intubating a patient with a feeding tube? Donning sterile gloves Verifying the health care provider's order Determining the patient's knowledge of the procedure Reviewing the patient's medical record for a history of nasal problems

Placing the patient in high-Fowler's position Rationale The appropriate nursing action for a patient diagnosed with pulmonary aspiration secondary to regurgitation of formula is to place the patient in a high-Fowler's position during the feeding and for 2 hours after the feeding is complete. Assessing the gag reflex is an appropriate action for a patient who experiences pulmonary aspiration secondary to a deficient gag reflux, not regurgitation of formula. The tube should be repositioned for a patient who experiences pulmonary aspiration secondary to a displaced tube, not regurgitation of formula. Tube placement should be verified before each intermittent feeding and every 4 to 6 hours for continuous feeding, not once per day. p. 1079

Which nursing action is appropriate when administering an enteral feeding to a patient who is diagnosed with pulmonary aspiration secondary to regurgitation of formula? Assessing gag reflex Repositioning the tube Verifying tube place once per day Placing the patient in high-Fowler's position

Programing the infusion pump at 10 to 40 mL per hour for the initial feeding Rationale The appropriate nursing action when advancing the rate of a continuous tube feeding is to program the infusion pump at 10 to 40 mL per hour for the initial feeding. A bolus of formula is infused over 20 to 30 minutes during the initial feeding for an intermittent, not continuous, tube feeding. A continuous feeding is advanced by 10 to 20 mL per hour, not 50 mL per hour, every 8 to 12 hours for a continuous feeding. p. 1076

Which nursing action is appropriate when advancing the rate of a continuous tube feeding? Infusing a bolus of formula over 20 to 30 minutes Advancing the rate by 60 to 110 mL per hour with every feeding Increasing the volume of formula by 50 mL per hour every 8 to 12 hours Programing the infusion pump at 10 to 40 mL per hour for the initial feeding

Infusing a bolus of formula over 20 to 30 minutes Rationale When advancing the rate of an intermittent tube feeding, the nurse should infuse a bolus of formula over a 20- to 30-minute period. The rate should be advanced by 60 to 120 mL, not 10 to 20 mL, per feeding. The infusion pump should be programed to administer 10 to 30 mL of formula each hour when advancing a continuous, not intermittent, tube feeding. The nurse should increase the volume of formula by 60 to 120, not 50, mL every 8 to 12 hours. p. 1076

Which nursing action is appropriate when advancing the rate of an intermittent tube feeding? Infusing a bolus of formula over 20 to 30 minutes Advancing the rate by 10 to 20 mL with every feeding Programing the infusion pump at 10 to 40 mL per hour Increasing the volume of formula by 50 mL every 8 to 12 hours

Observing the patient eat various consistencies of food Rationale The appropriate nursing action when observing a patient for dysphagia during an aspiration risk assessment is to watch the patient eat various consistencies of foods and liquids. This helps the nurse detect abnormal eating patterns such as frequent clearing of the throat or prolonged feeding time. While eliciting a gag reflex, measuring the oxygen saturation, and performing a nutritional screening are all appropriate nursing actions during an aspiration risk assessment, these actions are not performed when observing a patient for dysphagia during an aspiration risk assessment. p. 1083

Which nursing action is appropriate when observing a patient for dysphagia during an aspiration risk assessment? Eliciting a gag reflex Measuring the patient's oxygen saturation Performing a nutrition screening on the patient Observing the patient eat various consistencies of food

Explaining the sensations that are expected Rationale During the planning stage of intubating a patient with a prescribed feeding tube the nurse should explain the sensations the patient will experience during the procedure. The nurse may auscultate the patient's bowel sounds, but it is not necessary for intubation. Ice should not be applied to a plastic tube, and only one naris needs to be patent for this procedure. p. 1086

Which nursing action is appropriate when planning to intubate a patient with a prescribed feeding tube? Auscultating bowel sounds Applying ice to a plastic tube Examining both naris for patency Explaining the sensations that are expected

Instituting skin care measures for the patient Rationale The nurse should implement skin care measures for the patient who is prescribed enteral feedings and develops diarrhea to decrease the risk for perianal excoriation. Enteral feedings are held for patients who have two consecutive gastric residual volumes (GRVs) greater than 250 mL, not for a patient who develops diarrhea. The nurse would recheck the patient's gastric residual for volumes greater than 250 mL and not for a patient who develops diarrhea. Pancreatic enzymes are used to unclog enteral feeding tube, not to treat diarrhea. p. 1094

Which nursing action is appropriate when providing care to a patient who develops diarrhea three times or more in 24 hours as a result of enteral feedings? Holding the patient's current feeding Rechecking the patient's gastric residual in one hour Instituting skin care measures for the patient Obtaining a patient prescription for pancreatic enzymes

Suctioning the airway Rationale The patient who experiences pulmonary aspiration due to enteral feedings should have his or her airway suctioned by the nurse. Conferring with a dietician is appropriate for a patient who develops frequent diarrhea. Flushing the tube with water is appropriate for a patient whose enteral feeding tube is clogged. Instituting skin care measures is appropriate for a patient who develops diarrhea and is at risk for perianal excoriation. p. 1094

Which nursing action is appropriate when providing care to a patient who experiences pulmonary aspiration due to enteral feedings? Suctioning the airway Conferring with a dietician Flushing the tube with water Instituting skin care measures

Consult with the patient's dietician Rationale The nurse should consult with the dietician for a patient who is prescribed aspiration precautions and is experiencing weight loss. Clustering the patient's care decreases exertion but will not curb weight loss. An occupational therapist can address aspects of a patient's daily living activities but not nutrition. The pharmacist would require a prescriber's order to add calories to the patient's formula. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. p. 1084

Which nursing action is appropriate when providing care to a patient who is prescribed aspiration precautions and is experiencing weight loss? Cluster care for the patient Consult with the patient's dietician Initiate a consult with an occupational therapist Ask the pharmacist to add calories to the patient's formula

Elevating the head of the bed to a 90-degree angle Rationale The nurse should elevate the head of the bed to a 90-degree angle prior to feedings for any patient who is prescribed aspiration precautions. Eliciting a gag reflex and using a validated tool are appropriate nursing actions during the patient's aspiration assessment but not for the patient who is already prescribed aspiration precautions. A rest period of 30, not 60, minutes prior to meals is appropriate for a patient who is prescribed aspiration precautions. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. p. 1074

Which nursing action is appropriate when providing care to a patient who is prescribed aspiration precautions? Eliciting a gag reflex Using a validated assessment tool Providing a 60-minute rest period prior to meals Elevating the head of the bed to a 90-degree angle

Checking tube placement prior to each feeding Rationale 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. An x-ray film is often obtained to confirm placement prior to the initial tube feeding and before any feeding where the placement of the tube is questioned, but it is not necessary after each feeding. Tube placement is monitored every 4 to 6 hours for patients who are prescribed continuous, not intermittent, tube feedings. The tube is flushed with 30, not 15, mL of water to avoid clogging. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. p. 1077

Which nursing action is appropriate when providing care to a patient who is prescribed intermittent tube feedings? Obtaining an x-ray film after each feeding Monitoring tube placement every 4 to 6 hours Checking tube placement prior to each feeding Flushing the tube with 15 mL of water to avoid clogging

Using pancreatic enzymes The appropriate nursing action for a patient whose enteral feeding tube is clogged is to use pancreatic enzymes to unclog the tube. A dietician should be consulted if the patient develops diarrhea three times in a 24-hour period but not for a patient who has a clogged feeding tube. Rechecking the tube in an hour is an appropriate intervention for a patient who has a large gastric residual volume (GRV) but not for a patient whose feeding tube is clogged. Instituting skin care measures is more appropriate for a patient experiencing diarrhea, not for a patient whose enteral feeding tube is clogged.

Which nursing action is appropriate when providing care to a patient whose enteral feeding tube is clogged? Conferring with the patient's dietician Rechecking the patient's tube in 1 hour Instituting skin care measures for the patient Using pancreatic enzymes

Pulling the patient's tube steadily and smoothly Rationale When removing an enteral feeding tube from the patient, the nurse should pull the tube steadily and smoothly. The patient should be placed in high-Fowler's, not low-Fowler's, position. The end of the patient's tube should be kinked, not straightened. The patient should be instructed to take a deep breath and hold it, not exhale. p. 1089

Which nursing action is appropriate when removing an enteral feeding tube from the patient? Placing the patient in low-Fowler position Pulling the patient's tube steadily and smoothly Straightening the end of the patient's tube securely Instructing the patient to take a deep breath and exhale

Discarding gastric contents Rationale 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. pp. 1091-1092

Which nursing action is inappropriate when checking for gastric residual volume (GRV) before each enteral feeding? Discarding gastric contents Flushing the tube with 30 mL of air Administering the feeding for a gastric volume of 425 mL Pulling back slowly to aspirate the total volume of gastric contents

Warming the patient's formula to room temperature Rationale Cold formula causes gastric cramping and discomfort because the mouth and esophagus cannot warm the liquid; therefore, the nurse should warm the patient's formula to room temperature when administering a nasoenteric feeding. Checking the expiration date of the formula decreases the risk for obtaining tube feeding-borne gastrointestinal infection. Implementing hand hygiene reduces the transmission of microorganisms. Identifying the patient through the use of two identifiers ensures the correct patient will receive the procedure. p. 1090

Which nursing action prevents gastric cramping and discomfort during a nasoenteric feeding? Checking the expiration date of the formula Warming the patient's formula to room temperature Implementing hand hygiene prior to administering formula Identifying the patient using two identifiers prior to administering the formula

Using an infusion pump Rationale The nurse should use an infusion pump to promote the safety of a patient who is prescribed continuous enteral feeding. Auscultating to verify tube placement is not reliable enough for enhancing patient safety. The patient should be positioned in an upright, not supine, position to promote safety, and the nurse should use aseptic, not surgical, technique. p. 1082

Which nursing action promotes safety of a patient who is prescribed continuous enteral feeding? Using an infusion pump Auscultating for tube placement Placing the patient in a supine position Utilizing surgical technique when providing patient care

Allowing the open formula system to hang for no more than 8 hours Rationale An open formula system can hang for up to 8 hours; this is the nursing action that supports safety guidelines that are essential when providing care to a patient who is receiving a tube feeding. Medical, not surgical, aseptic technique is the expectation for this type of care. The head of the patient's bed should be placed at 30 to 45 degrees, not 90 degrees. Food coloring should be avoided, because it can cause hypotension, not decrease its risk. p. 1079

Which nursing action supports safety guidelines that are essential when providing care to a patient who is receiving a tube feeding? Using surgical aseptic technique Placing the patient's head of the bed at 90 degrees Allowing the open formula system to hang for no more than 8 hours Adding food coloring to enteral nutrition to decrease the risk for hypotension

Asking the patient to state his or her name and birth date Comparing the patient's name and medical record number on the order to the ID band Rationale The nurse should verify the patient using two identifies (i.e., patient's name and birthday or name and medical record number) according to agency policy. This can be accomplished by asking the patient to state his or her name and birth date or by comparing the patient's name and medical record number on the order to the ID band placed on the patient's wrist. Asking the patient if his name is Mr. Jones elicits a yes or no answer and is not supported by the Joint Commission, because it can result in mistakes. The patient's identity should not be verified by a family member, and the patient should not be asked compare medical record number and name to the provider's order, because this requires the ability to read. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 1083

Which nursing actions appropriately identify a patient prior to inserting a prescribed nasoenteric tube? Select all that apply. Asking the patient to state his or her name and birth date Asking the patient if he is Mr. Jones and to state his date of birth Verifying the patient's name and social security number by asking a family member Comparing the patient's name and medical record number on the order to the ID band Asking the patient to compare the medical record number and name to the provider's order

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 Rationale When checking for GRV before each enteral feeding, the appropriate nursing actions include flushing the tube with 30 mL of water, holding the feeding for an aspirate volume of 525 mL, and pulling back slowly to aspirate the total volume of gastric contents. The nurse should return, not discard, the gastric contents. The nurse should flush the tube with 10 to 30 mL of air, not 50 mL. pp. 1091-1092

Which nursing actions are appropriate when checking for gastric residual volume (GRV) before each enteral feeding? Select all that apply. Discarding gastric contents Flushing the tube with 50 mL of air 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

Drawing 30 mL of air into the syringe Planning the test after chest physiotherapy Checking tube placement every 4 to 6 hours Rationale Nursing actions that are appropriate when obtaining gastrointestinal (GI) aspirate for pH testing include drawing 30 mL of air into the syringe to check placement; planning the test when the continuous feeding would be stopped, such as during chest physiotherapy; and checking the tube placement every 4 to 6 hours. X-ray is used to verified placement prior to the first feeding and whenever the tube's placement is questioned, but not on a regular weekly basis. The nurse should wait to complete this procedure 60, not 15, minutes after medication administration. p. 1077

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 Verifying placement with a prescribed x-ray weekly Waiting at least 15 minutes after medication administration

Remove the plunger from the syringe Attach the barrel of the syringe to the end of the tube Fill the syringe with the measured amount of formula and elevate Rationale When preparing the syringe for an intermittent nasoenteric feeding to a patient, the nurse should remove the plunger from the syringe, attach the barrel of the syringe to the end of the tube, and fill the syringe with the measured amount of formula and then elevate. The other actions are incorrect: The nurse should pinch the proximal, not distal, end of the tubing. The formula should be administered by gravity and not pushed into the tube forcefully. p. 1092

Which nursing actions are appropriate when preparing the syringe for an intermittent nasoenteric feeding to a patient? Select all that apply. Pinch the distal end of the tubing Remove the plunger from the syringe Push the formula into the tube forcefully Attach the barrel of the syringe to the end of the tube Fill the syringe with the measured amount of formula and elevate

Choking Gagging Coughing Discomfort Rationale 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. The nurse should also instruct NAP to report any patient discomfort. Sneezing is not of particular concern during the administration of an enteral feeding. p. 1083

Which patient behaviors should the nurse instruct nursing assistive personnel (NAP) to report during the administration of an enteral feeding? Select all that apply. Choking Gagging Sneezing Coughing Discomfort

Infusing the patient's feeding per prescriber order Rationale The nurse can delegate the infusion of the patient's feeding per prescriber order to the nursing assistive person (NAP). The nurse, not the NAP, should be the one to verify tube placement or documenting the patient's tolerance of the procedure. Whereas patient positioning is a skill that can be delegated to the NAP, the appropriate position is for the patient's head of bed to be at least 30, not 25, degrees. p. 1090

Which skill should the nurse delegate to a nursing assistive person (NAP) when providing care to a patient who is receiving enteral feedings? Verifying the patient's tube placement Infusing the patient's feeding per prescriber order Placing the head of the patient's bed to 25 degrees Documenting the patient's tolerance of the procedure

Positioning the patient during insertion Rationale The nurse can delegate patient positioning during insertion to the nursing assistive personnel. Tube insertion, checking tube placement, and aspirating gastric content are tasks that nurses and physicians must handle. p. 1085

Which skill should the nurse delegate to nursing assistive personnel when providing care to a patient receiving enteral feedings? Inserting the patient's tube Checking the patient's tube placement Positioning the patient during insertion Aspirating gastric content from the patient

"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?" Rationale The Teach Back method is used to evaluate understanding of patient teaching related to any topic, including aspiration prevention and dysphagia. Stating to the patient that the nurse wants to be sure dysphagia and choking prevention were explained adequately and then asking the patient to explain the steps to protect against choking exemplifies this method; it allows the nurse to revise instruction or develop a plan for revised patient teaching if needed. Asking how the patient prevents choking and if he or she knows the Heimlich maneuver can be used to assess patient understanding, but not by asking the patient to teach back what he or she has learned. Telling the patient to relay information to his or her family does not assess understanding, which is a goal of the Teach Back method. p. 1084

Which statement by the nurse exemplifies the Teach Back method to determine patient and family understanding regarding dysphagia? "How do you currently prevent choking?" "Aspiration is life-threatening and should be taken seriously. Do you know the Heimlich maneuver?" "Now that I have explained dysphagia and choking prevention to you, I expect you to share this information with your family." "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?"