Adaptive Quizzing Chapter 45 nursing skills related to nutrition
Which are possible causes for constipation in a patient who is prescribed enteral tube feedings? Select all that apply. Inactivite Malabsorption Too much free water Lack of fiber in the diet Bacterial contamination
Inactivity Lack of fiber in the diet
Which nursing action is appropriate for a patient with a gastric aspirate of 150 mL? Return all the aspirate Discard all the aspirate Notify the health care provider Dilute the aspirate with water and return
Return all the aspirate
In which position should the nurse place the patient to conduct blood glucose monitoring? Prone Side-lying Semi-Fowler's Trendelenburg's
Semi-fowlers
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
Adding an additional 20 to 30 cm (8 to 12 in) to the measured length of the tube
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
Drawing 30 mL of air into the syringe Planning the test after chest physiotherapy Checking tube placement every 4 to 6 hours
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
Elevating the head of the bed to a 90-degree angle
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
Every 4 hours
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
Explaining the sensations that are expected
Which assessments should the nurse perform prior to inserting a nasoenteric tube for enteral feedings? Select all that apply. Height Weight Apical pulse Blood pressure Hydration status
Height Weight Hydration status
The nurse aspirates gastric contents to assess pH in a patient who is prescribed intermittent enteral feedings. In which order should the nurse perform the following actions? Mix the aspirate in the syringe. Dip the pH strip into the aspirate fluid. Observe the appearance of the aspirate Compare the color on the strip to the color chart. Expel a few drops of the aspirate into a clean medicine cup.
Observe the appearance of the aspirate Mix the aspirate in the syringe Expel a few drops of the aspirate into a clean medicine cup Compare the color on the strip to the color chart
The nurse is preparing to administer a nasoenteric feeding to a patient. In which order should the nurse perform the following actions? Fill the container with formula Shake the formula Hang the formula on an intravenous pole Cleanse the top of the formula can with alcohol prior to opening Open the roller clamp on tubing and fill to remove air
Shake the formula Cleanse the top of the formula can with alcohol prior to opening Fill the container with formula Open the roller clamp on tubing and fill to remove air Hang the formula on an intravenous pole
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
Side-lying
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
Suctioning the airway
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
Supine
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
Towel Stethoscope Water-soluble lubricant
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
Tube Patient Formula ENFit adapter
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
Type of tube Size of the tube pH value of gastric aspirate Confirmation of tube placement by x-ray film
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
Using an infusion pump
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
Verifying the health care provider's order
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
Watery stool over the last day An excessively snug external disk Redness and irritation at the insertion site
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
Allowing the open formula system to hang for no more than 8 hours
The nurse is performing blood glucose monitoring for a patient receiving parenteral nutrition. Place the steps of the procedure in the correct sequence. Explain procedure and purpose to patient and/or family. Clean puncture site with antiseptic solution. Wick blood drop into test strip. Check code on test strip vial. Assess area of skin to be used as puncture site. Read results and document in medical record. Gently squeeze fingertip until a drop of blood appears.
Assess area of skin to be used as puncture site. Explain procedure and purpose to patient and/or family. Check code on test strip vial. Clean puncture site with antiseptic solution. Gently squeeze fingertip until a drop of blood appears. Read results and document in medical record.
The nurse is assessing the patient prior to drawing a prescribed blood glucose level. In which order should the nurse perform the following actions? Determine if there are any risks for performing a skin puncture Assess the patient's understanding of the procedure Assess the skin at the site to be used for the procedure Review the health care provider's order for time of frequency of measurement Determine if certain conditions must be met prior to implementation of the procedure
Assess the patient's understanding of the procedure Assess the skin at the site to be used for the procedure Determine if there are any risks for performing a skin puncture Assess the skin at the site to be used for the procedure Review the health care provider's order for time of frequency of measurement Determine if certain conditions must be met prior to implementation of the procedure
Which nursing action is appropriate prior to administering a nasoenteric feeding? Monitoring the platelet count Drawing a red blood cell count Obtaining an arterial blood gas Assessing capillary blood glucose
Assessing capillary blood glucose
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
Consult with the patients dietician
Which complication may occur if the nurse were to add food coloring to the formula for a patient who is prescribed enteral feeding? Aspiration Hypotension Metabolic alkalosis Respiratory acidosis
Hypotension
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?"
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
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
Identifying the patient using two identifiers
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
Infusing a bolus of formula over 20 to 30 minutes
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
Instituting skin care measures for the patient
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
It reduces sepsis. It decreases hospital mortality. It maintains intestinal structure and function.
The nurse is intubating a patient with a feeding tube. In which order should the nurse perform the following actions? Anchor the tube to the patient's nose. Perform hand hygiene, and apply clean gloves. Stop, hold the end of the tube near the ear, and listen for air exchange when the tip of the tube reaches the carina. Insert the tube through the nostril to the back of the patient's throat. Encourage the patient to swallow by giving him or her small sips of water while advancing the tube.
Perform hand hygiene, and apply clean gloves. Insert the tube through the nostril to the back of the patient's throat. Encourage the patient to swallow by giving him or her small sips of water while advancing the tube. Stop, hold the end of the tube near the ear, and listen for air exchange when the tip of the tube reaches the carina. Anchor the tube to the patient's nose.
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
Performing hand hygiene
The nurse is preparing the syringe for an intermittent nasoenteric feeding to a patient. In which order should the nurse perform the following actions? Remove the plunger from the syringe Pinch the proximal end of the tubing Allow the formula to empty gradually by gravity Attach the barrel of the syringe to the end of the tube Fill the syringe with the measured amount of formula and elevate
Pinch the proximal end of the tubing 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 Allow the formula to empty gradually by gravity
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
Positioning the patient during insertion
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
Pulling the patient's tube steadily and smoothly
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
Rechecking the GRV in 1 hour
