ATI 54

A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (Select all that apply.) A. Review a signal the client can use if feeling any distress. B. Lay a towel across the client's chest. C. Administer oral pain medication. D. Obtain a Dobhoff tube for insertion. E. Have a petroleum-based lubricant available.

A. CORRECT: Before inserting an NG tube, it is important to establish a means for the client to communicate that she wants to stop the procedure. B. CORRECT: Placing a disposable towel across the client's chest provides for a clean environment. C. INCORRECT: Oral pain medication is not administered prior to the procedure because the purpose of the procedure is to remove stomach contents. D. INCORRECT: The type of tube to be used for gastric decompression is a Salem sump, Miller-Abbott, or Levin. A Dobhoff tube is used for feeding. E. INCORRECT: A water-based lubricant is used to reduce complications related to aspiration.

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following is an appropriate response by the nurse? A. "Water helps clear the tube so it doesn't get clogged." B. "Flushing helps make sure the tube stays in place." C. "This will help you get enough fluids." D. "Adding water makes the formula less concentrated."

A. CORRECT: Flushing the tube after instilling the feeding helps keep the NG tube patent by clearing any excess formula from the tube so that it doesn't clump and clog the tube. B. INCORRECT: Tape or a securing device, not flushing the tube with water, helps maintain the position of the NG tube. C. INCORRECT: If the client requires additional fluids, the small amount the nurse uses for flushing the NG tube will not be adequate. D. INCORRECT: If the formula is supposed to be less concentrated, the dietary staff will prepare it according to the client's prescription before the nurse instills it.

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding? (Select all that apply.) A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. D. Warm the formula to body temperature. E. Discard any residual gastric contents.

A. CORRECT: If the nurse cannot hear bowel sounds, the client's gastrointestinal tract might not be able to absorb nutrients. The nurse should then withhold feedings and notify the provider. B. CORRECT: The optimal position for enteral feeding is upright, and never lower than 30° of elevation of the head of the bed. Upright positioning helps prevent aspiration. C. CORRECT: Before administering enteral feedings, the nurse should verify the placement of the NG tube. The only reliable method is x-ray confirmation, which is impractical prior to every feeding. Testing the pH of gastric aspirate is an acceptable method between x-ray confirmations. D. INCORRECT: The enteral formula should be at room temperature, not body temperature. E. INCORRECT: Unless the volume of gastric contents is more than 250 mL or the facility has other guidelines in place, the nurse should return the residual to the client's stomach.

A nurse is teaching a group of nursing students about administering enteral feedings. Use the ATI Active Learning Template: Nursing Skill to complete this item. A. Indications: List at least four indications for enteral feedings. B. Nursing Actions (Intraprocedure): List the steps of administering an enteral feeding.

A. Indications ● Critical illness/trauma ● Neurological and muscular disorders - brain neoplasm, cerebrovascular accident, dementia, myopathy, Parkinson's disease ● Gastrointestinal disorders - enterocutaneous fistula, inflammatory bowel disease, mild pancreatitis ● Respiratory failure with prolonged intubation ● Inadequate oral intake B. Nursing Actions (Intraprocedure) ● Prepare the formula and a 60-mL syringe. ● Remove the plunger from the syringe. ● Hold the tubing above the instillation site. ● Open the stopcock on the tubing, and insert the barrel of the syringe with the end up. ● Fill the syringe with 40 to 50 mL of formula. ● If using a feeding bag, fill the bag with the total amount of formula for one feeding, and hang it to drain via gravity until empty (about 30 to 45 min). ● If using a syringe, hold it high enough for the formula to empty gradually via gravity. ● Continue to refill the syringe until the amount for the feeding is instilled. ● Follow with at least 30 mL of tap water to flush the tube and prevent clogging.

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. Auscultate breath sounds. B. Stop the feeding. C. Obtain a chest x-ray. D. Initiate oxygen therapy.

B. CORRECT: The greatest risk to the client is aspiration pneumonia. Therefore, the first action the nurse should take is to stop the feeding so that no more formula can enter the lungs. A. INCORRECT: Listening to the client's breath sounds is important whenever there is suspicion of aspiration. However, there is a higher assessment priority among these options. C. INCORRECT: Obtaining a chest x-ray is important whenever there is suspicion of aspiration. However, there is a higher assessment priority among these options. D. INCORRECT: Initiating oxygen therapy is important whenever there is suspicion of aspiration. However, there is a higher assessment priority among these options.

A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. Which of the following is the nurse's highest assessment priority before performing this procedure? A. Check how long the feeding container has been open. B. Verify the placement of the NG tube. C. Confirm that the client does not have diarrhea. D. Make sure the client is alert and oriented.

B. CORRECT: The greatest risk to the client receiving enteral feedings is injury from aspiration. Therefore, the priority nursing assessment before initiating an enteral feeding is to verify proper placement of the NG tube. A. INCORRECT: Checking that the container has not exceeded its expiration date, either for having it open or for opening it, is important. However, there is a higher assessment priority among these options. C. INCORRECT: Assessing the client for any possible complications of enteral feedings, such as diarrhea, is important. However, there is a higher assessment priority among these options. D. INCORRECT: Determining the client's level of consciousness is an assessment parameter that is ongoing and should precede any procedure. However, there is a higher assessment priority among these options.