ATI SM 3.0: Enteral Tube Feeding

A nurse is inserting a nasogastric tube for a pt & asks the pt to flex their head toward their chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by achieving which of the following? A. Closing off the glottis B. Preventing curling of the tube in the mouth C. Allowing the client to breathe through the mouth D. Opening the lower esophageal sphincter

A. Closing off the glottis Rationale: This action prohibits the tube from entering the trachea by closing it off and opening the esophagus.

A client who lives in a LTC facility is receiving intermittent enteral feedings & is experiencing social isolation. Which of the following interventions should the nurse recommend? A. Encourage the client to go to the dining room at meal times to talk with other clients B. Suggest that the client watch television while feedings are being administered C. Remind the client that they can have visitors after feeding administration times D. Ask the facility chaplain to speak with the client

A. Encourage the client to go to the dining room at meal times to talk with other clients Rationale: By encouraging the resident to maintain a normal schedule and social interactions, the nurse is helping to promote socialization and reverse patterns of isolation.

A nurse is preparing to administer a continuous enteral tube feeding to a client. The nurse should take which of the following actions to prevent a complication of the tube feeding? A. Limit the time the formula hangs to 8 hr. B. Flush the tube every 8 hr. C. Deliver the formula at a brisk rate D. Allow the feeding bag to empty before refilling it

A. Limit the time the formula hangs to 8 hr. Rationale: Formula that hangs longer than 12 hr for an open system and 48 hr for a closed system is at risk for spoilage of the formula or bacterial contamination, typically manifested as diarrhea.

A nurse is caring for a client who has a dysfunctional gastrointestinal tract and requires enteral feeding. Which of the following formulas should the nurse administer to the client? A. Modular B. Elemental C. Polymeric D. Specialty

B. Elemental Rationale: Elemental formulas contain predigested nutrients that are easy for a partially functional gastrointestinal tract to absorb.

A nurse is caring for a group of clients. The nurse should identify that which of the following clients requires an enteral tube feeding? A. A client who has a paralytic ileus B. A client who has recently experienced facial trauma C. A client who has dysphagia D. A client who has a decreased appetite

C. A client who has dysphagia Rationale: The nurse should identify that a client who is unable to swallow oral nutrition can benefit from enteral feedings.

A nurse is inserting a small-bore feeding tube. Before initiating the feeding, the nurse should take which of the following actions to verify placement? A. Measure the pH of gastric aspirate. B. Auscultate the epigastric area while injecting air. C. Obtain an x-ray. D. Place the open end of the tube in a cup of water.

C. Obtain an x-ray. Rationale: Obtaining an x-ray is the only reliable method for verifying initial placement of a small-bore feeding tube.

A nurse is caring for a client who has a paralytic ileus and requires nutritional support for approximately 2 weeks. Which of the following types of feeding tubes should the nurse anticipate the provider to prescribe? A. Nasogastric tube B. Nasointestinal tube C. Percutaneous endoscopic gastrostomy tube D. Percutaneous endoscopic jejunostomy tube

B. Nasointestinal tube Rationale: A nasointestinal tube allows post-pyloric feeding by depositing enteral formula directly into the intestines. This is an appropriate choice for a pt who lacks stomach motility (paralytic ileus) & requires short-term (less than 4 weeks) enteral feeding.

A nurse is providing teaching about risk for aspiration w/ a client who is receiving intermittent bolus nasogastric feedings. Which of the following findings should the nurse instruct the client to report? A. A feeling of fullness B. Persistent coughing C. Discomfort in the naris D. Post-feeding belching

B. Persistent coughing Rationale: A persistent cough can indicate that the distal end of the NG tube has moved into the respiratory tract. The pt should report this finding to nurse immediately because this is a risk for aspiration

To determine the length of a nasointestinal tube to insert, a nurse should measure the distance from the tip of the client's nose to the earlobe & from the earlobe to the... A. Umbilicus B. Xiphoid process C. Manubrium plus 10 to 20 cm more D. Xiphoid process plus 20 to 30 cm more

D. Xiphoid process plus 20 to 30 cm more Rationale: Measuring from the tip of nose to earlobe to xiphoid process approximates the distance from nose to stomach for 98% of clients. For duodenal or jejunal placement, an additional 20 to 30 cm is required.

A nurse is administering an enteral tube feeding to a client. Which of the following actions should the nurse take to prevent aspiration? A. Flush the feeding tube with 30 mL of water. B. Add blue food coloring to the enteral formula. C. Ensure the formula is at room temperature. D. Place the client in Fowler's position.

D. Place the client in Fowler's position. Rationale: Positioning a client in Fowler's position during a tube feeding can reduce the risk of regurgitation, which can lead to aspiration. If Fowler's is uncomfortable or contraindicated for the client, elevate the head of the client's bed to at least 30°.