NURA 1110 Exam 4 Nutrition
To determine the distance the NGT:
must be inserted to reach the stomach, measure from the *tip of the nose* to the *ear lobe* and from the *tip of the ear* to the *xiphoid* process.
NGT placed for *Gavage*
(getting) getting something via a NGT. EX: A patient who is malnourished may receive a NGT for feeding.
NGT placed for *Lavage*:
(leaving) removing content from the stomach. EX: Patient consumes toxic substances placement is use for removing it.
Preventing Common Complications for PEG tube: Nasal irritation or erosion:
- Check nostrils every shift for signs of pressure. - Clean and moisten nares every 4 to 8 hours. - Start feeding at slow rate.
Identify 2 methods of administering feedings through a gastric tube or enteral feeding tube:
1. Intermittent feedings 2. bolus feedings
What is The volume size (in mL) of the syringe used to administer "open system syringe" feedings to a patient with a gastric or enteral feeding tube. The plunger is removed from the syringe prior to the administration procedure, allowing the formula to flow via gravity.
60mL
11. (Select All That Apply) Which medications stimulate the patient's appetite? A. Megace B. Cyproheptadine C. Amitriptyline D. Steroids E. Folic Acid
A. Megace B. Cyproheptadine C. Amitriptyline D. Steroids
Special Diets: Pureed diet:
Also known as a blenderized liquid diet because the diet is made up of liquids and foods blenderized to liquid form. All foods are allowed. *Indications*: - After oral or facial surgery - chewing/swallowing difficulties
Nasogastric Tube (NGT) Placement and Care: Measurement of NGT length:
Another way to verify tube placement is to measure the length of the exposed tube after insertion and document this measurement. - Before each feeding, check tube length and compare findings with the initial measurement in conjunction with pH measurement and visual assessment of aspirate. - Any increase in the length of the exposed tube may indicate dislodgement. - Marking the tube with an indelible marker at the nostril and then assessing this marking each time the tube is used ensures that the tube has not become displaced.
12. (Select All That Apply)Choose the items you would place on a clear liquid diet food tray? A. Milk B. Jello C. Popsicles D. Apple Juice E. Ice Cream
B. Jello C. Popsicles D. Apple Juice
9. Which type of gloves doe the nurse use to insert a gastric tube? A.Sterile B. Non-Sterile/Clean
B. Non-Sterile/Clean
Special Diets: Clear liquid diet:
Composed only of clear fluids or foods that become fluid at body temperature. Requires minimal digestion and leaves minimal residue. Includes clear broth, coffee, tea, clear fruit juices (apple, cranberry, grape), gelatin, popsicles, commercially prepared clear liquid supplements. *Indications*: - Preparation for bowel surgery and lower endoscopy - Acute gastrointestinal disorders - Initial postoperative diet
Which is the most reliable method of confirming placement of a nasogastric tube (NGT)? A. Aspirating stomach contents and measuring pH B. Determining if the patient is able to speak C. Listening with a stethoscope while injecting air into the tube D. X-ray verification
D. X-ray verification
Special Diets: High fiber:
Emphasis on increased intake of foods high in fiber. *Indications*: - Prevent or treat constipation - Irritable bowel syndrome - Diverticulitis
NGT placed for *Compression*
If a patient is hemorraging (esophageal varices), a NGT would be placed for this.
A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take?
Instruct the client to tuck her chin when swallowing
Percutaneous Endoscopic Gastrostomy (PEG) Tube: What is it?
LONG-TERM NUTRITIONAL SUPPORT (enteral feeding) required for a long-term period, - enterostomal tube may be placed through an opening created into the stomach (gastrostomy) or into the jejunum (jejunostomy). - preferred route to comatose patient, because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings.
NGT placed for *Decompress*
Placement of a NGT for small bowel obstruction flatten the stomach
Special Diets: Renal diet:
Reduce workload on kidneys to delay or prevent further damage; control accumulation of uremic toxins. Protein restriction 0.6-1 g/kg/day; sodium restriction 1,000-3,000 mg/day; Potassium and fluid restrictions dependent on patient situation *Indications*: - Nephrotic syndrome - Chronic kidney disease - Diabetic kidney disease
Special Diets: Mechanically altered diet:
Regular diet with modifications for texture. Excludes most raw fruits and vegetables and foods with seeds, nuts, and dried fruits. Foods are chopped, ground, mashed or soft. *Indications*: - Chewing and swallowing difficulties - After surgery to the head, neck, or mouth.
Special Diets: Sodium-restricted diet:
Sodium limit may be set at 500-3000 mg/day *Indications*: - Hypertension - Heart failure - Acute/chronic renal disease - Liver disease
7. When checking the placement of a gastrostomy or jejunostomy tube, the nurse must make regular comparisons of: a. Tube length b. Gastric fluid c. pH d. Air pressure
a Tube length
Assist Patients with Eating and Feeding Patients with Dysphagia collaborate with:
o*speech therapy* for a swallow evaluation o*nutrition consult* accommodate for dietary modifications and preferences
Assist Patients with Eating and Feeding Patients with Dysphagia: utilize:
•a *NAPKIN* not a bib- in case of spills •Utilize specialized, adaptive eating utensils, cups, and equipment or straws when appropriate. USE CAUTION when using a straw for a patient with dysphagia- may worsen *choking* or risk for aspiration •Ensure that special adaptive or assistive devices (dentures, eyeglasses, hearing aids) are in place before beginning the meal •Avoid rushed or forced feeding- adjust the rate of feeding and size of bites to the pt's tolerance._
Assessment data indicating the need for a diuretic
* SOB* -Crackles -Jugular vein distention (JVD) * Wt. gain - Edema - Pink frothy sputum * Cough* - Ascites - Dec. peripheral perfusion * Fatigue* - Bounding Pulse - Dec. activity tolerance * Dyspnea* - Tachycardia - Orthopnea
Preventing Common Complications for PEG tube: GI symptoms (nausea/vomiting/abdominal distention):
- Check residual prior to intermittent feedings and every 4 hours during continuous feedings. - Avoid over-sedating client (delays gastric emptying). - Administer GI motility medications (metoclopramide), as ordered.
Preventing Common Complications for PEG tube: Stoma site irritation or infection:
- Clean skin every shift with soap and warm water. Dry thoroughly. - Use topical antibiotics and/or antifungals, as ordered. - Assess for signs of infection. - Request consult with wound care specialist, as needed.
Special Diets: Full liquid diet:
- Contain all the items on a clear liquid diet. Additional items allowed include milk and milk drinks, puddings, custards, plain frozen desserts, pasteurized eggs, cereal gruels, vegetable juices, and milk and egg substitutes in addition to clear liquids. - Liquids that can be poured at room temperature. High-calorie, high-protein supplements are recommended if this diet is used for more than 3 days.
Diuretic are used to treat what?
- Edema - Hypertension - Congestive heart failure - Liver disease - Kidney disorders
Preventing Common Complications for PEG tube: Clogged tubes:
- Flush tube before and after feeding, every 4 hours during continuous feeding, and after withdrawing aspirate. - Instill 30 mL of warm water with 50-mL or 60-mL syringe to attempt to unclog tube.
A nurse in a senior center is counseling a group of older adults their nutritional needs and considerations. Which of the following information should the nurse include? (select all that apply)
- Older adults are more prone to dehydration than younger adults are - Older adults need the same amount of most vitamins and minerals as younger adults do. - Many older men and women need calcium supplementation.
Preventing Common Complications for PEG tube: Diarrhea:
- Prevent contamination in both open and closed systems. - Change delivery set every 12 to 24 hours according to agency policy. - Refrigerate opened cans of formula and discard after 24 hours. - Limit hang time to 8 hours when using open system. - Use aseptic technique for patients who are immuno-suppressed or acutely ill. - Assess for fecal impaction.
Special Considerations with Total Parenteral Nutrition:
- Solutions are hypertonic. - Contains the three primary components necessary to maintain nutrition: proteins, carbohydrates, and fats. - Tailored to the individual patient's specific needs. - High glucose concentration, monitor blood glucose levels
Special Considerations with Peripheral parenteral Nutrition:
- Solutions are isotonic. - Contain lesser concentrations and amounts. - Physical incompatibility between the intravenous nutrition formula and other intravenous solutions, especially medications. - If the patient has a multilumen catheter in place, dedicate one lumen for the administration of the parenteral nutrition. -Do not use that lumen or administration set for any other purpose, to prevent incompatibility problems.
Preventing Common Complications for PEG tube: Aspiration:
- Use appropriate measures to check tube placement. - Elevate head of bed at least 30-45 degrees during feeding and for 1 hour afterward. - Give small, frequent feedings. - Avoid oversedation of patient. - Check residual volume per policy.
A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provide the body with the most energy?
Carbohydrates Carbohydrates are the body's greatest energy source; providing energy for cells is their primary function. They provide glucose, which burns completely and efficiently without end products to excrete. They are also a ready source energy, and they spare proteins from depletion.
2. A nurse is planning a high-energy diet for a patient. What nutrient provides energy to the body and should be increased in the diet? a. Carbohydrates b. Vitamins c. Minerals d. Water
a Carbohydrates
Nasogastric Tube (NGT) Placement and Care: What is it?
Short-Term Nutritional Support used for (less than 4 weeks) - Its a tube inserted through the nose and into the stomach. *Contraindications*: Pt's with: - Dysfunctional gag reflex - High risk of aspiration - Gastric stasis - Gastroesophageal reflux - Nasal injuries - Pt's that are unable to have the head of the bed elevated during feedings.
Pre-administration assessments for diuretics:
- depend upon the reason for administering the diuretic but should include at a minimum: VS and K+ level, urinary output, lung sounds, & edema. - Increases the potential for hypotension when given with anti-hypertensives.
Common diuretics
- furosemide (Lasix) - hydrochlorothiazide (HCTZ) - spironoloactone (Aldactone) - potassium sparing - bumetanide (Bumex) - mannitol
List 6 items utilized for gastric tube placement:
1. *Check tube placement* before administering any fluids, medications, or feeding, using multiple techniques: - x-ray, pH testing, aspirate characteristics, external length marking, and carbon dioxide monitoring 2. *Check gastric residual* before each feeding or every 4 to 6 hours during a continuous feeding. - High gastric residual volumes (200 to 250 mL or greater) can be associated with high risk for aspiration and aspiration-related pneumonia 3. *Assess the abdomen for abnormalities*. Assess for bowel sounds at least once per shift to check for the presence of peristalsis and a functional intestinal tract. 4. Make sure the *patient is as upright position* as possible during feeding. If the patient is in bed during feedings, elevate the head of the bed at least 30 degrees during feeding and for 1 hour afterward to prevent reflux and aspiration. 5. • *Prevent contamination* during enteral feedings by maintaining the integrity of the feeding system and using proper technique. *Closed systems*, consisting of a sterile, prefilled, ready-to-hang container, reduce the opportunity for bacterial contamination of the feeding formula. An *open system* exists when formula from a can or bottle is added to a feeding setup. Always check the expiration date of formula. 6. *Medications may be administered* through a feeding tube, but *never* give them while a feeding is being infused. Administer liquid forms of medications whenever possible. *Never add medications directly to the formula*; some drugs become ineffective when mixed with feeding formulas; medications mixed in feeding formulas may cause clogging of the feeding tube. It is very important to flush the tube with water before, between, and after the administration of medications.
Furosemide
1. Most commonly used diuretic 2. Loop diuretic 3. Administer IVP, IM, or PO IVP- dosages vary, dilute, and push slowly to prevent ototoxicity 4. Side Effects are Rare
Nasogastric Tube (NGT) Placement: •Steps of insertion:
1. Patient position: High Fowler position 90 degrees, or elevate the head of the bed 45 degrees if the patient is unable to maintain an upright position. 2.Measure the length of tubing needed: Measure the distance to insert the tube by placing the tip of the tube at the patient's nostril and extending the tube to the tip of the earlobe and then to the tip of the xiphoid process. Mark the tube with an indelible marker. 3. What PPE? Sterile gloves 4. Comfort measures and head positioning: ask the patient to slightly flex the head back against the pillow. While inserting the tube. Provide tissues for tearing or watering of eyes. Offer comfort and reassurance to the patient. 5. Once you are ready to advance the tube after you have reached the pharynx: Instruct the patient to touch the chin to the chest. Encourage the patient to sip water through a straw or swallow even if no fluids are permitted. Advance the tube in a downward and backward direction when the patient swallows 6. if: - Gagging/coughing: stop advancing the tube and check placement of the tube with tongue blade and flashlight. If the tube is curled, straighten the tube and attempt to advance again. Keep advancing the tube until pen marking is reached. - Resistance: Rotate tube if it meets resistance. - Distress/cyanosis: Discontinue the procedure and remove the tube - Secure the tube: a. Cut a 4-inch piece of tape and split the bottom 2 inches or use packaged nose tape for NG tubes. b. Place the unsplit end over the bridge of the patient's nose . c. Wrap split ends under and around the NG tube. Be careful not to pull the tube too tightly against the nose. - Care while NGT in place: - Assist with or provide oral hygiene at 2- to 4-hour intervals. - Lubricate the lips generously and clean nares and lubricate as needed. - Offer analgesic throat lozenges or anesthetic spray for throat irritation if needed.
Assess for signs of aspiration while eating:
1. Sudden appearance of severe coughing 2. Choking 3. Cyanosis 4. Voice changes 5. Hoarseness/gurgling after swallowing 6. Frequent throat clearing after meals 7. Regurgitation through the nose or mouth.
Prepare the food and tray to optimize patient's ability to feed self as much as possible:
1. open containers 2. cut meat 3. apply condiments
What is The amount of water used to flush the enteral tube after instilling each medication via the tube.
15mL
What is the Max amount of aspirated gastric residual volume (in mL) that can be re-instilled after a residual check to prevent fluid and electrolyte imbalances. More than this amount (or more than the formula flow rate for one hour) may indicate that the patient has delayed gastric emptying.
250mL
Select All That Apply)Which interventions will help decrease the risk of aspiration? A. Report signs and symptoms of dysphagia to the healthcare provided B. Raise the HOB so the patient's hips are flexed at 90 degrees C. Allow the patient to lie down and rest immediately after completing the meal D. Add thickener to thin liquids to create the consistency of mashed potatoes E. Allow rest periods during the feeding to avoid rushed/forced feeding.
A. Report signs and symptoms of dysphagia to the healthcare provided B. Raise the HOB so the patient's hips are flexed at 90 degrees D. Add thickener to thin liquids to create the consistency of mashed potatoes E. Allow rest periods during the feeding to avoid rushed/forced feeding.
Special Diets: Fat-restricted diet:
Low-fat diets are intended to lower the patient's total intake of fat. *Indications*: - Chronic cholecystitis (inflamed gallbladder) to decrease gallbladder stimulation. - Cardiovascular disease, to help prevent atherosclerosis
A nurse is caring for a client who is weighs 80kg (176lbs) and is 1.6(5ft 3 in)tall. Calculate her body mass index (BMI) and determine whether this client's BMI indicates that she is of a
Obese Step 1: client's weight(kg)and height(m)= 80kg and 1.6m Step 2: 1.6 x 1.6 = 2.56 m2 Step 3: 80/2.56 = 31.25
Special Diets: NPO:
This diet used before surgery to prevent aspiration related to anesthesia and after surgery until bowel sounds return. -Used for pt's undergoing certain medical tests - Pt's experiencing severe nausea and vomiting, an inability to chew or swallow, or various acute or chronic GI abnormalities; for those who are comatose; and for women during labor and delivery.
A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray?
Vanilla custard A low residue diet consist of foods that are low in fiber and easy to digest. Dairy products and eggs, such as custard and yogurt, are appropriate for low-residue diet.
4. The nurse is performing a nutritional assessment of an obese patient who visits a weight control clinic. What information should the nurse take into consideration when planning a weight reduction plan for this patient? a. To lose 1 pound/week, the daily intake should be decreased by 200 calories. b. One pound of body fat equals approximately 5,000 calories. c. Psychological reasons for overeating should be explored, such as eating as a release for boredom. d. Obesity is very treatable, and 50% of obese people who lose weight maintain the weight loss for 7 years.
c Psychological reasons for overeating should be explored, such as eating as a release for boredom.
Total parenteral nutrition:
a highly concentrated, hypertonic nutrient solution, accessed through a central venous line. - provides calories; restores nitrogen balance; and replaces essential fluids, vitamins, electrolytes, minerals, and trace elements. - can promote tissue and wound healing and normal metabolic function. - provides the bowel a chance to heal and reduces activity in the gallbladder, pancreas, and small intestine. - used to improve a pt's response to surgery
8. The nurse researches factors that may alter nutrition. Which statements accurately describe factors that influence nutritional status? (Select all that apply.) a. During adulthood, there is an increase in the basal metabolic rate with each decade. b. Because of the changes related to aging, the caloric needs of the older adult increase. c. During pregnancy and lactation, nutrient requirements increase. d. Nutritional needs per unit of body weight are greater in infancy than at any other time in life. e. Men and women differ in their nutrient requirements. f. Trauma, surgery, and burns decrease nutrient requirements.
c, d, e c. During pregnancy and lactation, nutrient requirements increase. d. Nutritional needs per unit of body weight are greater in infancy than at any other time in life. e. Men and women differ in their nutrient requirements.
6. A nurse is evaluating patients to determine their need for total parenteral nutrition (TPN). Which patients would be the best candidates for this type of nutritional support? Select all that apply. a. A patient with irritable bowel syndrome who has intractable diarrhea b. A patient with celiac disease not absorbing nutrients from the GI tract c. A patient who is underweight and needs short-term nutritional support d. A patient who is comatose and needs long-term nutritional support e. A patient who has anorexia and refuses to take foods via the oral route f. A patient with burns who has not been able to eat adequately for 5 days
a, b, f. Assessment criteria used to determine the need for TPN include an inability to achieve or maintain enteral access; motility disorders; intractable diarrhea; impaired absorption of nutrients from the GI tract (patient with celiac disease) and when oral intake has been or is expected to be inadequate over a 7- to 14-day period (Worthington & Gilbert, 2012; A.S.P.E.N., 2002). TPN promotes tissue healing and is a good choice for a patient with burns who has an inadequate diet. Oral intake is the best method of feeding; the second best method is via the enteral route. For short-term use (less than 4 weeks), a nasogastric or nasointestinal route is usually selected. A gastrostomy (enteral feeding) is the preferred route to deliver enteral nutrition in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Patients who refuse to take food should not be force fed nutrients against their will.
6. The nurse is assessing adequate nutrition for residents of a long-term care facility. Which strategies are recommended to address age-related changes affecting nutrition? (Select all that apply.) a. Avoid cold liquids with decreased peristalsis in the esophagus. b. Serve a variety of foods at each meal for loss of sense of taste and smell. c. Avoid eating right before bedtime for gastroesophageal reflux. d. Eat a high-fiber diet for slowed intestinal peristalsis. e. Eat more protein for lowered glucose tolerance. f. Offer large meals at frequent intervals for reduction in appetite and thirst sensation.
a, c, d a. Avoid cold liquids with decreased peristalsis in the esophagus. c. Avoid eating right before bedtime for gastroesophageal reflux. d. Eat a high-fiber diet for slowed intestinal peristalsis.
. Which nursing actions follow guidelines for preventing complications with enteral feedings? (Select all that apply.) a. Elevate the head of the bed at least 30 degrees during the feeding and for at least 1 hour afterward. b. Give large, infrequent feedings. c. Flush the tube before and after feeding. d. Clean and moisten the nares every 4 to 8 hours. e. Change the delivery set every other day according to agency policy. f. Check the residual before intermittent feedings and every 8 hours during continuous feedings.
a, c, d a. Elevate the head of the bed at least 30 degrees during the feeding and for at least 1 hour afterward. c. Flush the tube before and after feeding. d. Clean and moisten the nares every 4 to 8 hours.
2. Which examples of patients would the nurse expect to have an increase in BMR? (Select all that apply.) a. A toddler who is having a growth spurt b. An elderly patient who is in a long-term care facility c. A teenager who has been fasting to lose weight d. An adolescent who has a fever e. An adult who is going through an emotional time due to divorce f. An adult who has hypersomnia
a, d, e a. A toddler who is having a growth spurt d. An adolescent who has a fever e. An adult who is going through an emotional time due to divorce
4. As a nurse is aspirating the contents during a tube feeding, the nurse finds that the tube is clogged. What would be appropriate nursing interventions in this situation? (Select all that apply.) a. Use warm water and gentle pressure to remove clog. b. Flush with a carbonated beverage such as a cola soft drink. c. Use a stylet to unclog the tube. d. If necessary, replace the tube. e. Ensure that adequate flushing is completed after each feeding. f. Administer an antiemetic to the patient.
a, d, e a. Use warm water and gentle pressure to remove clog. d. If necessary, replace the tube. e. Ensure that adequate flushing is completed after each feeding
14. A nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurse's next action following this assessment? a. Use warm water and gentle pressure to remove the clog. b. Use a stylet to unclog the tubes. c. Administer cola to remove the clog. d. Replace the tube with a new one.
a. In order to remove a clog in a feeding tube, the nurse should try using warm water and gentle pressure to unclog it. A stylet should never be used to unclog a tube, and cola and meat tenderizers have not been shown effective in removing clogs. The nurse should first attempt to remove the clog, and if unsuccessful, the tube should be replaced.
7. A nurse is feeding a patient who states that she is feeling nauseated and can't eat what is being offered. What would be the most appropriate initial action of the nurse in this situation? a. Remove the tray from the room. b. Administer an antiemetic and encourage the patient to take small amounts. c. Explore with the patient why she does not want to eat her food. d. Offer high-calorie snacks such as pudding and ice cream.
a. The first action of the nurse when a patient has nausea is to remove the tray from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect.
8. A 62-year-old male patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition? a. Vitamin B malnutrition b. Obesity c. Dehydration d. Vitamin C deficiency
a. The need for B vitamins is increased in alcoholics because these nutrients are used to metabolize alcohol, thus depleting their supply. Alcohol abuse specifically affects the B vitamins. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI tract.
3. A nurse is feeding an elderly patient who has dementia. Which intervention should the nurse perform to facilitate this process? a. Stroke the underside of the patient's chin to promote swallowing. b. Serve meals in different places and at different times. c. Offer a whole tray of various foods to choose from. d. Avoid between-meal snacks to ensure hunger at mealtime.
a. To feed a patient with dementia, the nurse should stroke the underside of the patient's chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide between-meal snacks that are easy to consume using the hands.
9. A nurse is caring for a newly placed gastrostomy tube of a postoperative patient. Which nursing action is performed correctly? a. The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site. b. The nurse wets a washcloth and washes the area around the tube with soap and water. c. The nurse adjusts the external disk every 3 hours to avoid crusting around the tube. d. The nurse tapes a gauze dressing over the site after cleansing it.
a. When caring for a new gastrostomy tube, the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage. The nurse would not use a washcloth with soap and water on a new gastrostomy tube, but may use this method if the site is healed. Also, once the sutures are removed, the nurse should rotate the external bumper 90 degrees once a day. The nurse should leave the site open to air unless there is drainage. If there is drainage, one thickness of precut gauze should be placed under the external bumper and changed as needed to keep the area dry.
3. The nurse is assessing patients for BMR. Which patient would the nurse suspect would have an increased BMR? a. An elderly patient b. A patient who has a fever c. A patient who is fasting d. A patient who is asleep
b A patient who has a fever
9. Which nursing action associated with successful tube feedings follows recommended guidelines? a. Check tube placement by adding food dye to the tube feed as a means of detecting aspirated fluid. b. Check the residual before each feeding or every 4 to 8 hours during a continuous feeding. c. Assess for bowel sounds at least four times per shift to ensure the presence of peristalsis and a functional intestinal tract. d. Prevent contamination during enteral feedings by using an open system.
b Check the residual before each feeding or every 4 to 8 hours during a continuous feeding.
6. Which nursing action is performed according to guidelines for aspirating fluid from small-bore feeding tube? a. Use a small syringe and insert 10 mL of air. b. If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water. c. Continue to instill air until fluid is aspirated. d. Place the patient in the Trendelenburg position to facilitate the fluid aspiration process.
b If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water.
3. The nurse is attempting to insert an NG tube and, as the tube is passing through the pharynx, the patient begins to retch and gag. What nursing interventions are appropriate in this situation? (Select all that apply.) a. Inspect the other nostril and attempt to pass the nasogastric tube down that nostril. b. Ask the patient if he or she needs to pause before continuing insertion. c. Continue to advance tube when the patient relates that he or she is ready. d. Have the emesis basin nearby in case patient begins to vomit. e. Give small air boluses until gastric contents can be aspirated. f. Insert a nasointestinal tube.
b, c, d b. Ask the patient if he or she needs to pause before continuing insertion. c. Continue to advance tube when the patient relates that he or she is ready. d. Have the emesis basin nearby in case patient begins to vomit.
5. A nurse is removing an NG tube and notes epistaxis. What nursing interventions would the nurse perform in this situation? (Select all that apply.) a. Notify primary care provider and anticipate order to reinsert NG tube. b. Occlude both nares until bleeding has subsided. c. Offer facial tissue to blow nose. d. Record the amount of blood in the suction container. e. Ensure that patient is in upright position. f. Document epistaxis in patient's medical record.
b, e, f b. Occlude both nares until bleeding has subsided. e. Ensure that patient is in upright position. f. Document epistaxis in patient's medical record.
13. A nurse is inserting a nasogastric tube ordered for a patient to monitor bleeding in his GI tract. When the tube is being passed through the pharynx, the patient begins to cough and show signs of respiratory distress. What would be the priority action of the nurse upon this assessment? a. Keep the tube in place and notify the primary care provider immediately. b. Stop advancing the tube and pull it back into the nasal area. c. Ask the patient if he wants the nurse to stop the procedure. d. Call for help to perform CPR.
b. As the tube is passing through the pharynx and the patient begins to cough and show respiratory distress, the nurse should stop advancing the tube and pull it back into the nasal area. The nurse should also support the patient as he regains normal breathing ability and composure and have him try again if he feels able to.
4. A 56-year-old male patient who has COPD is refusing to eat. Which intervention would be most helpful in stimulating his appetite? a. Administering pain medication after meals. b. Encouraging food from home when possible. c. Scheduling his respiratory therapy before each meal. d. Reinforcing the importance of his eating exactly what is delivered to him.
b. Food from home that the patient enjoys may stimulate him to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and telling the patient what he must eat is no guarantee that he will comply.
1. A nurse is calculating the body mass index (BMI) of a 35-year-old male patient who is extremely obese. The patient's height is 5′6″ and his current weight is 325 pounds. What would the nurse document as his BMI? a. 50.5 b. 52.4 c. 54.5 d. 55.2
b. weight in pounds(325)/ -------------------------------- (ht in ins)(66)x(ht in inches)(66) x 703
10. A nurse is assessing the nutritional needs of patients. Which criteria indicates that a patient most likely needs TPN? a. Serum albumin level of 2.5 g/dL or less b. Residual of more than 100 mL c. Absence of bowel sounds d. Presence of dumping syndrome
c Absence of bowel sounds
8. Which method of feeding would a nurse normally provide if a patient can attempt eating regular meals during the day and is prepared to ambulate and resume activities? a. Continuous feeding b. Intermittent feeding c. Cyclic feeding d. Ambulatory feeding
c Cyclic feeding
5. What consideration based on gender would a nurse make when planning a menu for a male patient with well-defined muscle mass? a. Men have a lower need for carbohydrates. b. Men have a higher need for minerals. c. Men have a higher need for proteins. d. Men have a lower need for vitamins.
c Men have a higher need for proteins.
7. A home health care nurse is teaching a patient and caregivers how to administer an enteral feeding. Which teaching points are appropriate? (Select all that apply.) a. When checking residuals, routinely discard residuals to prevent an acid-base imbalance. b. When cleaning around a gastric tube insertion site, be careful not to rotate the guard after cleaning around it. c. Check for leaking of gastric contents around the insertion site (is guard too loose or balloon not filled adequately?). d. Clean around the gastric tube with soap and water, making sure it is adequately rinsed. e. Keep the head elevated while delivering a gastric feeding and for approximately an hour after the feeding. f. Mark gastrostomy tubes with an indelible marker and check the mark to make sure it is at the level of the abdominal wall.
c, d, e, f c. Check for leaking of gastric contents around the insertion site (is guard too loose or balloon not filled adequately?). d. Clean around the gastric tube with soap and water, making sure it is adequately rinsed. e. Keep the head elevated while delivering a gastric feeding and for approximately an hour after the feeding. f. Mark gastrostomy tubes with an indelible marker and check the mark to make sure it is at the level of the abdominal wall.
1. A nurse who is planning a diet for a patient who has anorexia chooses nutrients that supply energy to the body including: (Select all that apply.) a. Vitamins b. Minerals c. Carbohydrates d. Protein e. Water f. Lipids
c, d, f c. Carbohydrates d. Protein f. Lipids
15. A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient would the nurse report to the surgeon as possibly needing surgery to be postponed? a. A 19-year-old patient who is a vegan b. An elderly patient who takes daily nutritional drinks c. A 43-year-old patient who takes ginko bilboa and an aspirin daily d. An infant who is breast-feeding
c. A patient taking gingko biloba (an herbal), aspirin, and vitamin E (dietary supplement) may have to have surgery postponed due to an increased risk for excessive bleeding, because each of these substances have anticoagulant properties. Being a vegan should not affect surgery unless the patient has serious nutritional deficiencies. Drinking nutritional drinks and breast-feeding do not adversely affect the outcomes of surgery.
1. A nurse is estimating caloric requirements for a female patient whose healthy weight is 120 pounds and whose activity level is moderate. This patient's recommended total daily calories is: a. 1,200 b. 1,440 c. 1,560 d. 1,680
d 1,680
2. A nurse is helping an overweight female patient to devise a meal plan to lose 2 pounds per week. How many calories would the patient need to delete per day in order to accomplish this goal? a. 250 calories b. 500 calories c. 750 calories d. 1000 calories
d. 1 lb (0.45 kg) of body fat equals about 3,500 cal. Therefore, to gain or lose 1 lb (0.45 kg) in a week, daily calorie intake should be increased or decreased, respectively, by 500 cal (3,500 cal divided by 7 days = 500 cal/day). Similarly, a weight gain or loss of 2 lb (0.9 kg) per week would require an adjustment of 1,000 cal/day.
12. Which of the following nursing diagnoses would be most appropriate for a patient with a body mass index (BMI) of 18? a. Risk for Imbalanced Nutrition: More Than Body Requirements b. Imbalanced Nutrition: More Than Body Requirements c. Readiness for Enhanced Nutrition d. Imbalanced Nutrition: Less Than Body Requirements
d. A patient with a body mass index (BMI) of 18 is considered underweight, therefore a diagnosis of Imbalanced Nutrition: Less than Body Requirements is appropriate. The patient is not at risk for imbalanced nutrition because it is already a problem and certainly is not experiencing nutrition that is more than body requirements. Readiness for Enhanced Nutrition is appropriate when there is a healthy pattern of nutrient intake that is sufficient for meeting metabolic needs and can be strengthened and enhanced.
11. A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastric tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placement of the tube? a. Auscultate the bowel sounds. b. Measure the gastric aspirate pH. c. Measure the amount of residual in the tube. d. Order radiographic examination of the tube.
d. Although a radiographic examination exposes the patient to radiation and is costly, it is still the most accurate method to check correct tube placement. Other methods that can be used are aspiration of gastric contents and measurement of the pH of the aspirate. The recommended method for checking placement, other than a radiograph, is measuring the pH of the aspirate. Visual assessment of aspirated gastric contents is also suggested as a tool to check placement. In addition, the length of the exposed tube is measured after insertion and documented. Tube length should be checked and compared with this initial measurement, in conjunction with the previous two methods for checking tube placement. The auscultatory method is considered inaccurate and unreliable. Measurement of residual amount does not confirm placement.
10. A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient's diet should not be advanced? a. The patient consumed 75% of the liquids on her breakfast tray. b. The patient tells you she is hungry. c. The patient's abdomen is soft, nondistended, with bowel sounds. d. The patient reports fullness and diarrhea after breakfast.
d. Tolerance of diet can be assessed by the following: absence of nausea, vomiting, and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50% to 75% of the food on the meal tray.
5. A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient? a. Feed the patient solids first and then liquids last. b. Place the head of the bed at a 30-degree angle during feeding. c. Puree all foods to a liquid consistency. d. Provide a thirty-minute rest period prior to mealtime.
d. When feeding a patient who has dysphagia, the nurse should provide a 30-minute rest period prior to mealtime to promote swallowing; alternate solids and liquids when feeding the patient; sit the patient upright or, if on bedrest, elevate the head of the bed at a 90-degree angle; and initiate a nutrition consult for diet modification and food size and/or consistency.
Nasogastric Tube (NGT) Placement and Care: Confirmation of placements by:
o *Radiographic exam*: The standard procedure to verify initial placement of a feeding tube (most reliable) - X-ray only confirms the position of the tube at the time it was taken.(it can move) Placement must be checked frequently while the tube is in place. o *Assess aspirate*: The recommended method for checking placement, other than radiograph, is measuring the pH of the aspirate.(when continuous feedings are in use, pH becomes less helpful, because the nutritional formula buffers the pH of gastrointestinal secretions) - Visual assessment of aspirated gastric contents is also suggested as a tool to check placement o *Auscultate injected air*: An old technique of auscultation of air injected into a feeding tube has proved unreliable and may result in tragic consequences if used as an indicator of tube placement - Therefore, do not use it to confirm feeding tube placement.
Diuretics
referred to as water pills/fluid pills- causes the body to inc. urinary output) Therapeutic effect is diuresis
Peripheral parenteral nutrition:
the administration of nutritional support via the intravenous route, accessed in a peripheral vein. - Pt's who can't meet their nutritional needs by the oral or enteral routes may require intravenous nutritional supplementation. - prescribed for patients who have nonfunctional: - gastrointestinal (GI) - comatose - Pt's that need high caloric and nutritional needs due to illness or injury - pt's undergoing aggressive cancer therapy and those recovering from extensive burns, surgery, sepsis, or multiple fractures.
Providing Parenteral Nutrition: What is it?
the administration of nutritional support via the intravenous route. - Pt's who can't meet their nutritional needs by the oral or enteral routes may require intravenous nutritional supplementation.
When placing a nasogastric or nasoenteric tube:
the patient is placed in a high-Fowler's position to facilitate *passage of the tube* and to prevent *aspiration*.
Assist Patients with Eating and Feeding Patients with Dysphagia:
•Allow at least a *30 minute* rest period before mealtime and avoid administration of *sedatives and hypnotics* •Positioning: *90* degrees (high Fowler) •To enhance sense of taste: apply *mouth care* •Involve the patient as much as possible •Create a relaxed comfortable environment by sitting at pt's eye level and make eye contact.
Assist Patients with Eating and Feeding Patients with Dysphagia: Reduce
•Reduce *distractions* to allow attention on eating •Allow plenty of appropriate fluids and alternate with *solids*
