foundations 2 exam 2

The patient's wife is watching as the nurse prepares to insert a small bore feeding tube. She asks the nurse, "What is the purpose of the guide wire?" The nurse correctly responds: A) "Because placement must be verified by a chest x-ray, the guide wire is used to determine correct placement when it shows up on radiography." B) "To keep the patient from pulling the tube out as readily." C) "To serve as a guide to determine when the correct length of tubing has been inserted." D) "Because feeding tubes are flexible, a guide wire or stylet is used to provide rigidity that facilitates positioning."

"Because feeding tubes are flexible, a guide wire or stylet is used to provide rigidity that facilitates positioning."

Which statement made by the patient receiving a clear liquid diet indicates the need for further teaching? A) "I am glad that I can continue to have water to drink." B) "I plan on ordering two apple juices for tomorrow morning." C) "I am going to order milk to put in my coffee." D) "I hope that I can get my favorite orange Popsicles."

"I am going to order milk to put in my coffee."

The student nurse is preparing to administer medication through a feeding tube. Which of the following statements if made by the student nurse indicates correct understanding? A) "I will perform hand hygiene. Gloves are only necessary for tube insertion, not medication administration." B) "The head of the bed should be kept flat during medication administration." C) "I will aspirate gastric contents to check placement of the feeding tube and residual volume and then I will dispose of the aspirate properly." D) "I will flush with 10 mL of tap water after each medicine and with 30-60 mL of water after the last medication."

"I will flush with 10 mL of tap water after each medicine and with 30-60 mL of water after the last medication."

A group of nursing students are studying together. They are discussing the differences between parenteral and enteral nutrition. Which statement, if made by one of the students, indicates further instruction is needed? A) "Parenteral nutrition is the administration of nutrients directly into the GI tract by way of a feeding tube." B) "Enteral nutrition is preferred because it is less expensive than parenteral nutrition and maintains functioning of the gut." C) "An example of the parenteral route is subcutaneous or IM injections, or the IV route." D) "Gastric feedings may be given to patients with a low risk of aspiration. If there is a risk of aspiration, jejunal feeding is the preferred method. Parenteral nutrition is provided if the patient's GI tract is nonfunctional."

"Parenteral nutrition is the administration of nutrients directly into the GI tract by way of a feeding tube."

A patient with lung cancer has a feeding tube to help meet nutritional needs because of difficulty swallowing since radiation treatments. The patient requests some pain medication. The patient has an order for morphine, 5 mg IV push, every 2 hours as needed, or MS Contin (extended-release morphine tablet) 30 mg every 8 hours as needed. You return with the injectable form to be administered IV. The patient seems upset by this, stating, "I take a morphine pill for pain; why are you bringing me a shot?" What is your best response? A) "This is the same medication only in a form that I can administer through your IV line. The pill form you took at home should never be crushed, so I am unable to administer it through your feeding tube. This is the safest route for your pain medication to be administered at this time." B) "Your physician has ordered pain medication that may be administered either IV or through your feeding tube. To administer medications through your feeding tube, the medications must first be crushed, and it is simply easier to administer the pain medication through your IV." C) "This is the same medication you have taken at home only in a form that I can administer through your IV. It will take effect quicker than if I crushed your medication and administered it through your feeding tube." D) "I have brought you pain medication that can be administered through your IV, but if you prefer to have the pill form, I can go prepare it to be administered through your feeding tube."

"This is the same medication only in a form that I can administer through your IV line. The pill form you took at home should never be crushed, so I am unable to administer it through your feeding tube. This is the safest route for your pain medication to be administered at this time."

The nurse is inserting an NG feeding tube. Which of the following supplies will the nurse need to perform the procedure? (Select all that apply.) A) Saline nasal spray B) 8 to 12 Fr feeding tube C) 60 mL syringe D) Stethoscope E) Tube fixation device F) Tincture of benzoin G) Sterile specimen cup H) Cup of water/straw

-8 to 12 Fr feeding tube -60 mL syringe -Stethoscope -Tube fixation device -Tincture of benzoin -cup of water/straw

Which of the following patients may benefit from enteral nutrition? (Select all that apply.) A) A patient who has a brain injury B) A patient with oral cancer C) A patient with paralytic ileus D) A patient with burns of the lower extremities

-A patient who has a brain injury -A patient with oral cancer -A patient with burns of the lower extremities

When should placement of a feeding tube be verified? (Select all that apply.) A) Before administering formula through the tube B) Before administering medications through the tube C) Before administering water through the tube D) At least once every 6 hours when continuous feedings are given E) If the patient is complaining of a sore throat F) Only when the physician orders it

-Before administering formula through the tube -Before administering medications through the tube -Before administering water through the tube -At least once every 6 hours when continuous feedings are given

Identify the appropriate times to verify enteral tube placement by pH testing. (Select all that apply.) A) Before each intermittent feeding B) At least once every 6 hours during continuous feedings C) Before administration of medications through the tube D) After administration of medications through the feed

-Before each intermittent feeding -At least once every 6 hours during continuous feedings -Before administration of medications through the tube

You are developing a nursing care plan to reduce the risk for aspiration in a patient. Which interventions will help to reduce the risk? Select all that apply. A) Check gastric residual volume every 4 hours. B) Infuse enteral feeding no faster than 50 mL/hr. C) Elevate head of bed at least 30 degrees. D) Administer 60 mL of water every 4 hours. E) Check tube placement per protocol.

-Check gastric residual volume every 4 hours. -Elevate head of bed at least 30 degrees. -Check tube placement per protocol.

You are attempting to administer medication through a feeding tube but are unable to do so because of a blockage in the tube. What action(s) should you take? (Select all that apply.) A) For a newly inserted tube, notify physician and obtain x-ray confirmation of positioning. B) Clamp the tube and try again at a later time. C) For an established tube, attempt to flush tube with large-bore syringe and warm water. D) Soak the end of the tube in warm water. E) If unable to flush, contact physician for replacement of tube and potential need to reroute medication. F) Have the patient place the chin to the chest and swallow.

-For a newly inserted tube, notify physician and obtain x-ray confirmation of positioning. -For an established tube, attempt to flush tube with large-bore syringe and warm water. -If unable to flush, contact physician for replacement of tube and potential need to reroute medication.

The physician just left the patient's room after explaining the options of NG or NI feeding tube placement. A student asks a nurse about the differences between nasogastric and nasointestinal feedings. Which of the following are accurate statements made by the nurse? (Select all that apply.) A) Insertion of an NG tube requires clean gloves, whereas insertion of an NI tube requires sterile gloves. B) It would be unexpected for there to be more than 10 mL of gastric aspirate obtained from an NI tube or more than 200 mL from an NG tube. C) The advantage to an NI tube is that there is less risk for aspiration. D) NI tubes are used for patients with nasal problems such as nosebleeds or deviated septums. NG tubes are used for patients without nasal problems. E) Both NG and NI tubes are usually used for less than 30 days.

-It would be unexpected for there to be more than 10 mL of gastric aspirate obtained from an NI tube or more than 200 mL from an NG tube. -The advantage to an NI tube is that there is less risk for aspiration. -Both NG and NI tubes are usually used for less than 30 days.

For safe administration of oral medications through a feeding tube, specific attention must be paid to: (Select all that apply.) A) Proper placement of the tube B) The patient's temperature C) Whether the medication can be crushed for administration through the tube D) The patient's electrolyte status

-Proper placement of the tube -Whether the medication can be crushed for administration through the tube

Which of the following medications should never be given through a feeding tube? (Select all that apply.) A) Liquid medications B) Elixirs C) Sublingual tablets D) Enteric-coated (EC) E) Sustained release (SR) F) Extended release (XR) G) Long acting (LA) H) Large tablets or pills

-Sublingual tablets -Enteric-coated (EC) -Sustained release (SR) -Extended release (XR) -Long acting (LA)

You have inserted an NG feeding tube. The patient vomited during insertion and continues to gag. What action(s) should you take? (Select all that apply.) A) Suction airway as needed. B) Place patient in high-Fowler's position. C) Remove feeding tube. D) Position patient on side. E) Contact physician for possible chest x-ray. F) Have patient sip ice water.

-Suction airway as needed. -Remove feeding tube. -Position patient on side. -Contact physician for possible chest x-ray.

A patient is receiving a continuous enteral feeding by infusion pump. You enter the patient's room to verify tube placement and measure residual. You notice that the patient's respirations are shallow and rapid and that the patient's color is ashen. You find rhonchi upon auscultation, and the patient appears to be coughing up sputum of a color similar to the formula feeding. What action(s) should you take? (Select all that apply.) A) Ask the patient if she feels short of breath. B) Administer oxygen. C) Turn off the tube feeding. D) Have the patient deep breathe and cough. E) Position the patient in Fowler's position and suction the patient. F) Position patient on the left side and suction the patient. G) Notify the physician. H) Prepare for chest x-ray examination.

-Turn off the tube feeding. -Position the patient in Fowler's position and suction the patient. -Notify the physician. -Prepare for chest x-ray examination.

Which of the following are accurate statements related to the use of water and administering medication through a feeding tube? (Select all that apply.) A) Cold water should be avoided as it may cause abdominal cramping. B) Tap water as hot as possible should be used to enable the medications to dissolve. C) The feeding tube should be flushed with 10 mL of water after each medication is administered. D) Patients who receive tube feedings do not require water. E) The feeding tube should be flushed with 30 to 60 mL of water after the last medication. F) Any time water is administered through the feeding tube, the amount should be documented on the intake and output record.

-cold water should be avoided as it may cause abdominal cramping. -The feeding tube should be flushed with 10 mL of water after each medication is administered. -The feeding tube should be flushed with 30 to 60 mL of water after the last medication. -Any time water is administered through the feeding tube, the amount should be documented on the intake and output record.

Identify signs and symptoms of accidental respiratory migration of a feeding tube. (Select all that apply.) A) Coughing B) Choking C) Cyanosis D) Sore throat E) Distention

-coughing -choking -cyanosis

The patient is presently receiving intermittent tube feedings of 120 mL every 6 hours. The physician's orders state: Jevity formula feeding 240 mL every 6 hours per feeding tube, increase per patient tolerance. Which of the following assessment data indicate patient intolerance of the tube feeding and therefore inability of the rate to be increased? (Select all that apply.) A) Diarrhea B) Abdominal distention and discomfort C) Nausea D) Flatulence E) Thirst F) Residual volume greater than 200 mL

-diarrhea -abdominal distention and discomfort -nausea -residual volume greater than 200 mL

Complications of tube feedings into the intestines include: (select all that apply) A. Diarrhea. B. Dehydration. C. High blood pressure. D. Constipation. E. Jaundice

-diarrhea -dehydration

Complications of a TF into the stomach include: (select all that apply) A. Regurgitation. B. Aspiration pneumonia. C. Ulcer. D. Gastric atrophy. E. Edema.

-regurgitation -aspiration pneumonia

Which of the following, if exhibited by the patient, may increase the risk for spontaneous enteral tube dislocation? (Select all that apply.) A) Nausea B) Ambulation C) Vomiting D) Frequent nasotracheal suctioning E) Severe bouts of coughing F) H2 antagonists

-vomiting -frequent nasotracheal suctioning -severe bouts of coughing

Sequence the procedure for verifying feeding tube placement. A) Measure pH of aspirate. Compare the color of the strip with the color on the chart provided by the manufacturer. B) Discard used supplies, remove gloves and discard, and perform hand hygiene. C) Draw back on syringe and obtain 5 to 10 mL of gastric aspirate. Observe appearance of aspirate. D) Perform hand hygiene. Apply clean gloves. Draw up 30 mL of air into syringe, then attach to end of feeding tube. Flush tube with 30 mL of air.

1. D 2. C 3. A 4. B

Before checking for GRV, the nurse should inject how much air into the tube? A. 10 ml B. 30 ml C. 45 ml D. 60 ml

30 mL

What is the maximum amount of time an enteral feeding should be held while medications are being administered? A. 30 minutes B. 60 minutes C. 90 minutes D. 2 hours

30 minutes

Formulas for infants should have a hang time of how long? A. Every 24 hours B. 8 hours C. 12 hours D. 4 hours

4 hours

The nurse is checking the placement of a tube just inserted in a patient before initiating enteral feedings. Which pH would lead the nurse to suspect that the tube is in the tracheobronchial tree? A) 1 B) 3 C) 5 D) 7

7

What is the difference between a PEG tube and a gastrostomy tube? A) A PEG tube is inserted into the jejunum; a gastrostomy tube is located in the stomach. B) A PEG tube exits from the right upper quadrant and a gastrostomy tube exits from the upper left quadrant. C) A PEG tube is inserted through the abdominal wall and a gastrostomy tube is inserted through the nose. D) A PEG tube is inserted by using endoscopic visualization of the stomach and is held in place by its design; a gastrostomy tube is inserted surgically and is held in place by sutures.

A PEG tube is inserted by using endoscopic visualization of the stomach and is held in place by its design; a gastrostomy tube is inserted surgically and is held in place by sutures.

The nurses are discussing feeding tube migration and prevention. Which of the following statements indicates correct understanding? A) As long as the external portion of a feeding tube is taped in place, the tube will be unable to migrate out of position. B) A feeding tube can enter the airway without causing obvious respiratory symptoms. C) The nurse should have the patient deep breathe and cough and suction the patient frequently. D) The nurse should keep the head of the bed flat to reduce the risk of tube migration.

A feeding tube can enter the airway without causing obvious respiratory symptoms.

A patient received an NG tube for decompression after an appendectomy. The patient's postoperative pain orders include oral and IV morphine. When the patient reports abdominal pain, which action should the nurse take? A. Administer IV morphine. B. Administer the oral morphine via the NG tube. C. Remove the NG tube to decrease the abdominal pain. D. Administer the morphine by mouth and clamp the NG tube for 30 minutes.

Administer IV morphine.

Which of the following may be delegated to NAP? A) Administering medication through a feeding tube B) Administering a tube feeding C) Verifying feeding tube placement D) Inserting an NG feeding tube E) Assessing for peristalsis

Administering a tube feeding

You observe a confused patient pulling at her NG feeding tube. As you retape the tube to the bridge of the patient's nose, you notice that the mark on the tube has moved away from the naris. What action should you take? A) Advance the tube until the mark is even with the naris and verify correct tube placement. B) Secure the tape on the patient's nose well with the tube in the current location. C) Remove the tube. D) Restrain the patient's hands before leaving the room. E) Pull back on the tube.

Advance the tube until the mark is even with the naris and verify correct tube placement.

The nurse is reading the physician's orders to increase the rate of the patient's NG feeding. Which of the following orders should the nurse question? A) Isocal 150 mL per feeding tube every 4 hours, increase by 50 mL per feeding per day until total volume is achieved to meet patient's caloric needs according to dietician's referral. B) Finger-stick blood glucose every 6 hours until maximum administration rate is achieved and maintained for 24 hours. C) Advance tube feeding rate by 100 mL/hr every 8 to 12 hours to target rate of 250 mL/hr over 12 hours. D) Weigh patient daily until maximum administration rate is reached and maintained for 24 hours, then weigh patient 3 times per week.

Advance tube feeding rate by 100 mL/hr every 8 to 12 hours to target rate of 250 mL/hr over 12 hours.

The nurse is going to administer an intermittent tube feeding. Since the patient's feeding tube has been in place for 3 days, which action is best for the nurse to take at this time? A) Obtain an order for x-ray verification of tube location. B) Auscultate over the gastric area while instilling 30 mL of air into the feeding tube. C) Aspirate gastric contents and test on a pH strip. D) Verify the indelible ink mark on the tube is at the nares.

Aspirate gastric contents and test on a pH strip.

The nurse is preparing to administer an intermittent tube feeding to a patient. When is the most appropriate time to verify enteral feeding tube placement? A. Before the feeding B. After the feeding C. Halfway through the feeding D. Before each feeding with a repeat x-ray

Before the feeding

A patient had an NG feeding tube inserted 1 week ago. You notice that the patient's nasal mucosa is inflamed, and the patient complains of pain at the site of insertion. The other naris appears patent with intact skin. What is the best action to take at this time? A) Call the physician; get an order to remove the feeding tube and insert a new feeding tube in the opposite naris. B) Remove the feeding tube and reinsert it in the opposite naris. C) Apply triple antibiotic ointment at the site of insertion and leave the tube in place. D) Medicate the patient for pain and stop using the feeding tube.

Call the physician; get an order to remove the feeding tube and insert a new feeding tube in the opposite naris.

Which intervention is a priority in decreasing the risk for infection in a patient receiving parenteral nutrition? A) Check the patient's temperature every 4 hours. B) Ambulate patient 4 times per day. C) Change dressing per protocol using aseptic technique. D) Monitor serum glucose level every 6 hours.

Change dressing per protocol using aseptic technique.

What is the best method of verifying proper feeding tube placement before each medication administration? A. Ensure that the tube is in its original taped position. B. Obtain radiograph verification. C. Use auscultation to listen for gastric activity. D. Check for GRV.

Check for GRV

Between medication doses and during periods when a bolus enteral feeding is not being administered via an NG tube, which action should the nurse take? A. Remove the NG tube. B. Keep the NG tube connected to the enteral feeding bag. C. Keep the NG tube open to air. D. Clamp the proximal end of the NG tube and cap its end.

Clamp the proximal end of the NG tube and cap its end.

Why is it important to have the tube feeding at room temperature? A) It is unnecessary to keep the tube feeding cold because it will be hanging at room temperature anyway. B) It aids the speed of digestion. C) Cold formula can cause gastric cramping. D) Cold formula may lower the patient's body temperature.

Cold formula can cause gastric cramping.

How should the nurse determine if the patient's NG tube has become displaced? A. Compare the external length to the initial external length. B. Listen over the patient's abdomen while inserting air into the tube. C. Watch the gastric returns for change in fluid color. D. Check the pH of the NG tube aspirate.

Compare the external length to the initial external length.

A patient has an order for an enteric-coated medication via a gastrostomy tube. Which action should the nurse perform? A. Crush the medication and mix it with more than 30 ml of water. B. Hold the medication and leave a note for the practitioner. C. Consult the pharmacist and practitioner to determine an acceptable alternative. D. Crush the medication and mix it with as little water as possible.

Consult the pharmacist and practitioner to determine an acceptable alternative.

Purified or sterile water is used for flushing and medication preparation. What is the definition of purified water? A. Water free of any microorganisms B. Water flowing from the site of storage C. Contaminant-free water as result of treatment such as distillation or ultrafiltration D. Nonsaline, fresh water

Contaminant-free water as result of treatment such as distillation or ultrafiltration

The nurse suspects the patient's feeding tube has migrated. Which of the following would indicate the greatest risk related to tube migration? A) Dyspnea and decreased oxygen saturation B) Pain and gastric aspirate hemoccult positive C) Absence of bowel sounds D) Inability to flush the feeding tube

Dyspnea and decreased oxygen saturation

Which technique is appropriate when caring for a patient who has an NG tube in place for decompression after gastric surgery? A. Reposition the NG tube every 4 hours to prevent occlusion. B. Flush the tube via the air vent lumen. C. Elevate the head of the bed, unless contradicted. D. Flush the main lumen of the tube using 10 ml of air.

Elevate the head of the bed, unless contradicted.

While preparing the enteral feeding, the nurse should not take which action? A. Ensure that the formula is cold. B. Check the formula expiration date. C. Identify and confirm the EN label. D. Ensure that the correct tubing is used.

Ensure that the formula is cold.

How do enteral and parenteral nutrition differ? Select the correct response below. a. Enteral is administered via a vein; parenteral via the ilium. b. Enteral is administered via a blood vessel; parenteral via the mouth. c. Parenteral is administered via GI tract; enteral via a site outside the GI tract. d. Enteral is administered via the GI tract; parenteral via a site outside the GI tract. e. Enteral is administered via the stomach; parenteral via the small intestine.

Enteral is administered via the GI tract; parenteral via a site outside the GI tract.

The patient is receiving EN through a continuous open enteral feeding system. How often should the nurse change the system? A. Every 8 hours B. Every 12 hours C. Every 4 to 8 hours D. Every 48 hours

Every 4 to 8 hours

Which finding in a patient receiving enteral feedings at 80 mL/hr through a nasointestinal tube needs further follow-up? A) Gastric residual volume is 100 mL for the last 4 hours. B) Gastric aspirate is dark brown with a foul odor. C) Patient had two formed stools during the previous 24-hour period. D) Patient has active bowel sounds during morning assessment.

Gastric aspirate is dark brown with a foul odor.

Hold feeding, notify physician, maintain patient in semi-Fowler's position, and recheck in 1 hour

Gastric residual exceeds 200 mL.

The patient is receiving a continuous enteral feeding. Which of the following assessment findings would require follow-up? A) Gastric residual of 250 mL B) Bowel sounds present in all 4 quadrants C) pH of gastric contents 5.0 D) Less than 10 mL of aspirate from NI tube

Gastric residual of 250 mL

When giving more than one medication via a PEG tube, the nurse should follow which procedure? A. Mix the medications in a medicine cup and administer them together and then flush the tube. B. Give each medication separately and flush between medications with at least 15 ml of purified or sterile water. C. Put all the medications into the syringe one after another and flush afterwards with 30 ml of water. D. Give each medication separately without flushing between medications.

Give each medication separately and flush between medications with at least 15 ml of purified or sterile water.

The nurse is providing an intermittent enteral feeding. How quickly should the feeding be given? A. Gradually over 30 to 60 minutes B. Within 20 minutes C. Over 24 hours D. As quickly as possible

Gradually over 30 to 60 minutes

Which technique helps ensure placement of an NG tube into the esophagus and the stomach as opposed to the lung? A. Have the patient swallow water before the tube is inserted. B. Hyperextend the patient's neck. C. Have the patient look up at the ceiling. D. Have the patient use the chin-tuck position

Have the patient use the chin-tuck position

Which of the following are contra-indications for tube feedings? Select the correct response below. a. Hypomotility of the small intestine. b. Functioning GI tract, but patient cannot meet nutritional needs orally. c. Severe Dysphagia. d. Low output GI fistulas. e. Protein energy malnutrition.

Hypomotility of the small intestine.

Which action should be taken before removal of a patient's NG tube? A. Explain to the patient that discomfort will be similar to when the tube was inserted. B. Insert a small bolus of air into the lumen to clear fluid from the tube. C. Instruct the patient to exhale forcefully just before removal. D. Tell the patient not to blow his or her nose for 20 minutes after removal.

Insert a small bolus of air into the lumen to clear fluid from the tube.

Which of the following is an appropriate nursing action to prevent a complication of NG tube feedings? A) Keeping the head of the patient's bed elevated at least 30 degrees B) Leaving the feeding tube unclamped and unplugged between feedings C) Allowing the syringe to empty of feeding before adding more to the syringe D) Changing the feeding tube bag and tubing every 72 hours for a continuous feeding

Keeping the head of the patient's bed elevated at least 30 degrees

In preparation for an intermittent enteral feeding, the nurse should take which action? A. Place the patient on the left side to prevent aspiration. B. Make sure that the formula is at room temperature. C. Make sure that the formula is still cold. D. Place the patient in the supine position

Make sure that the formula is at room temperature.

Patient with burns who cannot consume enough calories orally

NG tube

The patient has an NG tube connected to low constant suction. Which intervention is the most important for assessing proper NG tube function? A. Monitoring stool status B. Reviewing serum electrolyte levels C. Monitoring urine output D. Observing the NG tube's aspirate

Observing the NG tube's aspirate

A nurse is teaching a student nurse about initial verification of enteral feeding tube placement. The nurse asks the student nurse which is the most reliable way to verify placement. Which answer indicates that the student nurse understood the information? A. Auscultating an air bolus B. Observing the color of aspirated fluid C. Obtaining an x-ray D. Checking pH of aspirated fluid

Obtaining an x-ray

For intestinal placement of a feeding tube, in what position should the nurse place the patient while waiting for radiological confirmation of correct placement? A) On the patient's right side B) In a high-Fowler's position C) In a left lateral position D) Lying flat

On the patient's right side

Patient with difficulty swallowing after having a CVA and will need long-term nutritional support.

PEG tube

Patient with malabsorption syndrome

Parenteral nutrition

Turn off tube feeding, place in Fowler's position, suction, and notify physician.

Patient aspirates formula.

Notify physician and confer with dietitian to determine need to modify type of formula, concentration, or rate of infusion.

Patient develops diarrhea

Withhold tube feeding and notify physician. Be sure tubing is patent; aspirate for residual.

Patient develops nausea and vomiting

Enteral feedings are not indicated for which patients? A. Patients with impaired swallowing B. Patients who cannot eat for one day because of surgery C. Patients with a nutrition deficit D. Patients receiving mechanical ventilation

Patients who cannot eat for one day because of surgery

The nurse is inserting an NG feeding tube. Which step in the procedure is inaccurate, indicating further instruction is needed? A) Perform hand hygiene and place patient in left lateral position. Determine length of tube from the xyphoid process to the tip of the patient's nose. Insert stylet into feeding tube. Inspect nares. Dip end of tube in ice water. B) Hand patient a cup of water with a straw. Gently insert the tube through the nostril to back of throat. Have patient flex head toward chest. Give small sips of water and advance the tube as patient swallows. Rotate tube 180 degrees while inserting. C) When tip of tube reaches carina, stop and listen for air exchange from distal portion of tube. Continue to advance tube until desired length has been passed. Check back of throat with a penlight and tongue blade. Check placement of tube. D) Mark exit site on tube with indelible ink. Apply tincture of benzoin to nose and allow to become "tacky." Remove gloves and apply stabilization device. Obtain an x-ray to verify tube placement. Document.

Perform hand hygiene and place patient in left lateral position. Determine length of tube from the xyphoid process to the tip of the patient's nose. Insert stylet into feeding tube. Inspect nares. Dip end of tube in ice water.

To administer a gelcap via an NG tube, the nurse should perform which action? A. Dissolve the gelcap in a cup of hot water and stir it with a spoon. B. Pierce the gelcap and empty the contents into purified or sterile water. C. Contact the pharmacist for an acceptable alternative medication. D. Cut the gelcap open and salvage as much liquid as possible.

Pierce the gelcap and empty the contents into purified or sterile water.

Which intervention is a comfort measure that can ease the discomfort of NG tube insertion? A. Inform the patient beforehand that tube insertion will be quite uncomfortable so he or she is not surprised. B. Have the patient hold an emesis basin to collect any vomit caused by tube insertion. C. Provide a focal point for the patient, such as something to hold and squeeze as desired. D. Place a pillow under the patient's head and tip the patient's head back so he or she is comfortable.

Provide a focal point for the patient, such as something to hold and squeeze as desired.

The patient begins to cough and choke as the nurse is inserting the NG tube. What is the best action for the nurse to take at this time? A) Pull the feeding tube out and start over in the opposite naris. B) Pull the tube back and attempt to reinsert. C) Instruct the patient to take small sips of water and swallow. D) Auscultate over the carina.

Pull the tube back and attempt to reinsert.

What should be done if resistance is encountered during the initial attempt to insert an NG tube? A. Twist the tube back and forth and force it past the resistance. B. Pull the tube back slightly and angle it downward. C. Stop the procedure and notify the practitioner. D. Lubricate the tube again and reinsert it into the same naris.

Pull the tube back slightly and angle it downward.

You are caring for a patient newly diagnosed with diabetes mellitus who states that he needs to make changes in his eating habits and patterns. Which nursing diagnosis is most appropriate to include on the nursing care plan? A) Readiness for enhanced nutrition B) Feeding self-care deficit C) Risk for aspiration D) Imbalanced nutrition: less than body requirements

Readiness for enhanced nutrition

The nurse is educating the patient and family on the use of enteral feeding tubes. Which information is important to include in the education plan? A. Use a regular syringe to irrigate the feeding tube every 2 hours. B. Report persistent gagging, coughing, vomiting, or abdominal distention. C. Test the pH of the gastric fluid to verify the initial placement of the tube. D. Explain that the nurse will check the enteral feeding tube placement every 6 hours

Report persistent gagging, coughing, vomiting, or abdominal distention.

The nurse is taking steps to unclog the enteral feeding tube. What is the appropriate action for the nurse to take after using an enzyme-containing declogging solution or mechanical declogging device? A. Report the obstruction to the practitioner if the clog remains. B. Crush one uncoated pancreatic enzyme tablet and administer into the tube. C. Instill warm water into the tube using a 10-ml syringe. D. Clamp the feeding tube.

Report the obstruction to the practitioner if the clog remains.

You are to irrigate the patient's established feeding tube with 30 mL of tap water before instilling the tube feeding. Upon attempting to do so, you find that you are unable to instill the fluid. What should your next action be? A) Notify the physician. B) Irrigate the tubing with soda, such as Coca-Cola. C) Reposition the patient. D) Use a smaller-sized syringe with the plunger to push the fluid through the feeding tube.

Reposition the patient.

You attempt to aspirate gastric contents from an established NG feeding tube and get zero return. What should you do next? A) Document the finding. B) Reposition the patient. C) Assume that the tube is in the appropriate place and start the tube feeding. D) Get an order for a chest x-ray to verify placement before administering the tube feeding. E) Remove the tube and insert a new one.

Reposition the patient.

The nurse is going to administer a bolus enteral tube feeding of 240 mL. The nurse has obtained a pH of 4 and 50 mL of gastric aspirate. Based on these findings, what action should the nurse take? A) Stop the feeding and recheck the residual in one hour. B) Reposition the feeding tube under fluoroscopy. C) Discard the aspirate and continue with the bolus feeding as prescribed. D) Return the aspirate to the patient's stomach and administer the feeding.

Return the aspirate to the patient's stomach and administer the feeding.

The nurse checks the GRV of a patient who has a gastrostomy tube and obtains 150 ml. Which action should the nurse take next? A. Discard the aspirate and begin the infusion. B. Hold the feeding for 1 hour. C. Return the aspirate to the stomach and begin the infusion. D. Hold the feeding and notify the practitioner.

Return the aspirate to the stomach and begin the infusion.

A patient had a procedure and must remain supine but needs a gastric enteral feeding. How should the nurse position the patient to receive the enteral feeding? A. Trendelenburg position B. Reverse Trendelenburg position C. On the right side D. On the left side

Reverse Trendelenburg position

The nurse is flushing a feeding tube before medication administration. What is the appropriate liquid to use for flushing and medication preparation? A. Soda B. Juice C. Sterile water D. Extra formula

Sterile water

The nurse checks the pH of aspirated fluid from an enteral feeding tube in a patient who has been fasting. According to the pH strip, the reading is less than 5. What should the nurse suspect is the source of the fluid? A. Small intestine B. Esophagus C. Tracheobronchial tree D. Stomach

Stomach

If the nurse suspects the NG feeding tube has migrated, the nurse should: A) Instill 10 mL of water into the feeding tube, reinsert the stylet, and reposition the tube. B) Stop any enteral feedings and obtain an order for a chest x-ray to determine placement. C) Irrigate the tube with tap water. D) Reposition the patient from side to side

Stop any enteral feedings and obtain an order for a chest x-ray to determine placement.

A patient's oxygen saturation level has fallen from 97% to 90% during a coughing spell, even though the small-bore enteral feeding tube appears to be intact. Which action should the nurse take first? A. Lower the head of the bed. B. Stop the continuous enteral feeding. C. Assess the patient's breath sounds. D. Notify the practitioner.

Stop the continuous enteral feeding.

Which of the following actions by the nurse help reduce the risk of aspiration? A) The nurse elevates the head of the bed. B) The nurse performs nasotracheal suctioning before instilling a tube feeding. C) The nurse encourages the patient to deep breathe and cough. D) The nurse keeps the patient well hydrated.

The nurse elevates the head of the bed.

The nurse is inserting an NG feeding tube for the first time. Which action, if made by the nurse, indicates that further instruction is needed? A) The nurse dips the end of the tube into a glass of water. B) The nurse has the patient flex the head as the tube is inserted into the naris. C) The nurse aims back and down toward the ear. D) The nurse advances the tube as the patient swallows.

The nurse has the patient flex the head as the tube is inserted into the naris.

The nurse verified feeding tube placement by pH testing and administered the regularly scheduled medications at 10 a.m. The nurse flushed the feeding tube with 10 mL of water between medications and with 30 mL of water after the last medication. It is now 10:45 a.m. and the patient is requesting pain medication. The only pain medication ordered is to be administered per feeding tube. What action should the nurse take at this time? A) The nurse may administer the pain medication but it is unnecessary to recheck placement with a pH strip since it was verified within the last hour. B) The nurse should verify placement with a pH strip and administer the medication but avoid flushing afterwards since this would result in the patient receiving too much water within a short period of time. C) The nurse should call the physician and request a different route for pain medication administration since it would be contraindicated per tube at this time. D) The nurse should verify placement with a pH strip, administer dissolved medication, and flush with 30 mL of water.

The nurse should verify placement with a pH strip, administer dissolved medication, and flush with 30 mL of water.

The nurse is about to begin a gastric enteral feeding. Which patient characteristic would make the nurse stop the process and notify the practitioner? A. The patient cannot lie supine. B. The patient has absent bowel sounds. C. The patient has an allergy to the formula. D. The patient has diarrhea.

The patient has an allergy to the formula.

What diameter tube should be used for a tube feeding? A. The smallest diameter through which the formula barely moves. B. The smallest diameter through with the enteral formula freely flows. C. A medium diameter. D. The largest possible diameter

The smallest diameter through with the enteral formula freely flows.

What does an unexpected change in GRV indicate? A. Increased GRV indicates that the tube is in the small intestine. B. Decreased GRV indicates that the tube is in the stomach. C. The tube has moved from the esophagus into the stomach. D. The tube may have moved out of the correct position.

The tube may have moved out of the correct position

Which of the following is NOT an appropriate technique for administering enteral formulas? A) Continuous feeding pump B) Through a large vein C) Intermittent gravity drip D) Large-bore syringe (bolus)

Through a large vein

Reposition patient, attempt to flush with large-bore syringe and warm water; if able to flush and absence of residual, determine the patient's risk of dislodgment—if risk is low and the tube has remained taped in original position, start next feeding.

Unable to aspirate gastric contents

While administering a medication via an NG tube, the nurse notices that the initial 15-ml water flush does not flow freely. Which action should the nurse take first? A. Remove the syringe from the NG tube and add water to the medication. B. Remove the NG tube and reinsert one that is not clogged. C. Use a feeding pump to ensure medication delivery. D. Using a 30- to 60-ml syringe and warm water, apply a gentle back-and-forth motion to the plunger.

Using a 30- to 60-ml syringe and warm water, apply a gentle back-and-forth motion to the plunger.

A patient is going to have an NG tube inserted. Which action should the nurse take next after entering the patient's room, performing hand hygiene, and donning gloves? A. Estimate the length of the tube to be inserted. B. Ensure that the patient agrees to treatment. C. Explain the procedure to the patent. D. Verify the correct patient using two identifiers

Verify the correct patient using two identifiers

A patient has just had an NG tube inserted for medication administration. What is the best way to accurately verify its placement? A. Inject air into the stomach. B. Aspirate gastric contents. C. Verify through radiographic examination. D. Measure the pH of aspirated contents.

Verify through radiographic examination

Which factor may increase the risk of tube displacement? A. Oral suctioning B. The pH of aspirated fluid from the tube C. The volume of fluid aspirated through the tube D. Vomiting or coughing

Vomiting or coughing

When should a tube feeding be recommended? Select the correct response below. When a person has an inadequate oral nutrient intake for 2 - 4 days. a. When a person has severe diarrhea. b. When GI tract works, but patient cannot meet nutrient needs orally. c. When a person has severe acute pancreatitis. d. When a person has severe dysphagia.

When a person has severe dysphagia.

You just inserted an NG feeding tube. The physician's order states to administer all meds per tube and a continuous feeding of Isocal at 30 mL per hour. The order also states to check the patient's blood glucose every 6 hours. When can you begin to instill feedings, water, or medications through the feeding tube? A) Immediately after placement is verified by pH testing B) When the patient's blood glucose is verified to be within normal limits C) When tube placement has been verified by x-ray film D) After administering 30 mL of water, the medications may be given, followed by another 30 mL of water, and then the continuous feeding may be initiated

When tube placement has been verified by x-ray film

Which of the following accurately describes the greatest risk related to having a feeding tube? A) Electrolyte imbalance B) Fluid volume overload C) Infection D) Aspiration

aspiration

A patient has a nasogastric feeding tube. The nurse is aware of the need to monitor the patient for potential complications. Which of the following symptoms, if demonstrated by the patient, would potentially indicate the greatest risk related to tube feedings? A) Diarrhea B) Dyspnea C) Abdominal distention D) Throat irritation

dyspnea

The physician's order reads flush NG tube with 30 to 50 ml saline solution for irrigation q2h prn. The nurse knows that saline solution is used instead of water because: a. water is irritating to the gastric mucosa. b. saline is better in maintaining tube patency. c. flushing with water can deplete electrolytes in the stomach. d. the sterility of the stomach is maintained with saline solution.

flushing with water can deplete electrolytes in the stomach

Before inserting an NG tube, the nurse should alert the patient that he or she may experience which sensation as the tube passes the back of the throat? A. Burning B. Tickling C. Gagging D. Fullness

gagging

The nurse aspirates stomach contents from a newly inserted feeding tube. The nurse is aware the patient has been on the proton-pump inhibitor omeprazole (Pepcid). The pH strip reads "3." Where should the nurse expect the x-ray to determine placement of the feeding tube? A) In the lungs B) In the esophagus C) In the stomach D) In the small intestine

in the stomach

When a patient has a risk of aspiration, which type of tube should be used to deliver EN? A. Gastrostomy tube B. Nasogastric tube C. Jejunostomy tube D. Orogastric tube

jejunostomy tube

A nurse is caring for a patient with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The patient's electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L. Based on these laboratory findings, the nurse selects which solution to use for nasogastric tube irrigation? a. Tap water b. Distilled water c. Sterile water d. Normal saline

normal saline -why is this answer correct? Patient has a low serum sodium

Which of the following pH test results on the aspirate of a patient who receives intermittent feedings indicates that the feeding tube is in the stomach? A) pH of 1 to 4 B) pH of 6 or greater C) pH greater than 5 D) pH of 0 to 14

pH of 1 to 4

Which finding assessed on physical examination of a patient is a possible indicator of malnutrition? A) Heart rate of 88 beats per minute B) Shiny hair C) Spoon-shaped nails D) Pinkish red oral mucous membranes

spoon-shaped nails

he nurse is preparing to aspirate fluid from a nasointestinal tube. The nurse should expect the appearance of the aspirated fluid to be what color? A. Clear B. Yellow C. Red D. Dark brown

yellow