Enteral Nutrition

What will the nurse need before removing a patient's nasogastric tube? Evidence of hypoactive bowel sounds in all quadrants Absence of abdominal pain and distention Assurance that the patient can pass flatus A health care provider's order

A health care provider's order CORRECT. The nasogastric tube may be removed only with a health care provider's order.

Why does the nurse elevate the head of the bed to 30 degrees for a patient receiving an intermittent tube feeding? Elevating the head of the bed reduces the risk for aspiration. Proper elevation of the head of the bed promotes the patient's digestion. Acid reflux is reduced when the head of the bed is elevated at least 30 degrees. Nutrients are absorbed more efficiently when the head of the bed is elevated.

Elevating the head of the bed reduces the risk for aspiration. CORRECT. Elevating the head of the bed reduces the risk for aspiration

What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube? Examine each naris for patency and skin breakdown. Place the patient in the high-Fowler's position. Anesthetize the throat. Have the patient take a few sips of water.

Examine each naris for patency and skin breakdown. CORRECT. Examining each naris for patency and signs of skin breakdown will help the nurse determine which naris will accommodate a nasogastric tube with less discomfort.

Which patient does not have a medical condition that contraindicates placement of a nasogastric tube? A 28-year-old patient who fractured a femur after heavy drinking A 73-year-old patient who is on anticoagulation therapy. A 54-year-old patient who broke a cheekbone in a fall A 67-year-old patient with a history of unexplained nosebleeds

28-year-old patient who fractured a femur after heavy drinking CORRECT. Neither the patient's broken femur nor the patient's alcohol consumption would contraindicate placement of a nasogastric tube.

. How could the nurse assess the patency of a nasogastric (NG) tube being used for enteral nutrition? Elevate the head of the patient's bed to at least 30 degrees. Use an intravenous fluid infusion set. Check the gastric residual volume. Monitor the amount of intake the patient tolerates in an 8-hour period.

Check the gastric residual volume. CORRECT. The nurse would check gastric residual volume. Doing so could determine the patency of the feeding tube.

What would the nurse do if he or she were not able to insert a nasogastric tube in either of a patient's nares? Ask another nurse to attempt the insertion. Document the attempts in the patient's medical record. Notify the physician that the attempts were unsuccessful. Allow the patient to rest for 30 minutes before resuming the process.

Notify the physician that the attempts were unsuccessful. CORRECT. The nurse would notify the physician because he or she will need to attempt to insert the tube or determine another treatment option.

After unsuccessfully attempting to flush a nasogastric (NG) tube with water, what is the most appropriate action for the nurse to take? Flush the tube with ginger ale. Use apple juice to flush the tube. Obtain a product designed to unclog NG tubes. Force-flush the system with sterile normal saline.

Obtain a product designed to unclog NG tubes. . CORRECT. If the feeding tube becomes clogged, the nurse should obtain and use an unclogging product for feeding tubes.

What is the proper response to the nurse's observation that the patient's closed-system enteral feeding has 150 mL of formula remaining and that the infusion order rate is for 50 mL/hr? Recalculate the present drip factor for accuracy. Terminate the fluid, and prepare to hang a new bag of formula. Plan to check the feeding for completion within the next 3 hours. Check with the pharmacy to see if the formula has been hanging too long.

Plan to check the feeding for completion within the next 3 hours. CORRECT. Because the ordered dose is 50 mL/hr, checking for completion within 3 hours is the right choice

Which intervention might the nurse delegate to nursing assistive personnel (NAP) when inserting a nasogastric tube? Positioning the patient in a high-Fowler's position Assessing the patient's abdomen for bowel sounds Determining any history of unexplained nosebleeds Educating the patient about the need for the intervention

Positioning the patient in a high-Fowler's position CORRECT. Positioning the patient is within NAP scope of practice.

How might the nurse minimize the patient's anxiety when removing a nasogastric tube? Administer a mild sedative prescribed by the patient's health care provider. Ask the patient's caregiver to emotionally support the patient during the removal. Provide reassurance of what will happen during the procedure and talk the patient through the process. Instruct the patient to take deep, calming breaths while revisiting a pleasant

Provide reassurance of what will happen during the procedure and talk the patient through the process. CORRECT. Letting the patient know what to expect during an intervention usually reduces anxiety.

What patient care might the nurse delegate to nursing assistive personnel (NAP) when a patient's nasogastric tube is removed? Assessing the patient for abdominal distention Providing the patient with mouth care Documenting tube removal Checking for bowel sounds

Providing the patient with mouth care CORRECT. The skill of mouth care may be delegated to NAP.

Which nursing action is appropriate when feeding gastric residual is 50 mL? Return it to the stomach via the feeding tube. Dispose of the residual contents down the commode. Discard the stomach contents as a liquid biohazard. Return half of the volume to the stomach, and discard the rest.

Return it to the stomach via the feeding tube.. CORRECT. If the volume of the residual stomach contents is less than 250 mL, it can be returned to the stomach via the feeding tube.

Why does the nurse kink the nasogastric tube before removing it from a patient? To suppress the cough reflex To keep any fluid from flowing out To hinder the gag reflex To prevent transmission of microorganisms

To keep any fluid from flowing out CORRECT. Kinking the tube keeps any residual fluid in the tube from flowing out.

What would minimize the nurse's risk for contamination during the removal of a nasogastric tube? Wearing treatment gloves Providing the patient with an emesis basin Protecting the patient's chest with an absorbent towel Discarding any soiled tissues in the biohazard receptacle

Wearing treatment gloves CORRECT. Wearing gloves will protect the nurse from contamination.

What would the nurse do if he or she encountered resistance when inserting a nasogastric tube? Ask the patient to cough. Withdraw the tube to the nasopharynx. Encourage the patient to swallow. Instruct the patient to hyperextend the neck.

Withdraw the tube to the nasopharynx. CORRECT. If the patient starts to cough, experiences a drop in oxygen saturation, or shows other signs of respiratory distress, withdraw the tube into the posterior nasopharynx until normal breathing resumes. Do not force the tube or push it against resistance.