Foundations Test 2
The nurse is preparing to insert a small-bore feeding tube and is providing patient education regarding how the patient can assist with the passage of the tube. Which instruction should be provided to the patient?
"Tip your head forward and swallow when I tell you to."
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?
Administer IV morphine
What is the maximum amount of time an enteral feeding should be held while medications are being administered?
30 minutes
A patient is receiving a continuous enteral feeding via a small-bore feeding tube. The nurse is preparing to irrigate the tube. How much fluid should the nurse use to irrigate the tube?
30 ml
Before checking for GRV, the nurse should inject how much air into the tube?
30 ml
A patient is being discharged from the hospital on enteral feedings. The nurse teaches the family member to add formula to the bag and allow it to hang for what period of time?
4 hours
Formulas for infants should have a hang time of how long?
4 hours
A confused patient inadvertently removes a newly inserted long-term EAD. What should the nurse do?
Apply a dry sterile dressing to the site, notify the practitioner, and anticipate immediate tube replacement.
The nurse is performing care on a patient with a PEG tube. Upon assessment of the site, the nurse finds that the bumper has become embedded or "buried" in the skin. Where should the bumper be positioned?
Approximately 0.5 to 1.5 cm (0.2 to 0.6 in) above the skin and moving freely without pressure on the skin
The nurse's goal is to prevent health care-associated infections and tissue injury in patients with small-bore feeding tubes. To accomplish this goal, the nurse should perform which action?
Assess the oral cavity and perform oral care according to the organization's practice.
The nurse is inserting a feeding tube in an older adult patient who was recently in a motor vehicle crash. What is an absolute contraindication for nasal insertion of a feeding tube in this patient?
Basilar skull fracture
A patient is admitted with multiple injuries, including facial trauma, after a motor vehicle crash. The advanced practice nurse is preparing to insert a small-bore feeding tube. Because of potential complications, the nurse knows there is a critical need to review the patient's medical history and assess for associated injuries that would prevent tube insertion. Which complications are absolute contraindications to nasal insertion?
Basilar skull fracture and transsphenoidal surgical procedures
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?
Before the feeding
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?
Clamp the proximal end of the NG tube and cap its end.
How should the nurse determine if the patient's NG tube has become displaced?
Compare the external length to the initial external length.
A patient who is receiving chemotherapy has been getting enteral feedings at home. After 2 weeks, she has lost 2.75 kg (6 lb) and reports feeling very weak and tired. While discussing her regimen with the nurse, she indicates that getting enough feeding and fluid during the day is difficult. What suggestion for the patient is appropriate?
Comparing the amount of recommended feeding to the amounts of previous usual meals and daily fluid intake
A patient has an order for an enteric-coated medication via a gastrostomy tube. Which action should the nurse perform?
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?
Contaminant-free water as result of treatment such as distillation or ultrafiltration
A patient who is undergoing radiation treatments for head and neck cancer is to begin feeding via a G tube because his mouth is very sore and adequate fluid and nutrition is difficult for him to get orally. The practitioner wants him to continue to eat and drink by mouth as he is able. The nurse establishes a plan with him and suggests that he take which action?
Continue to try eating meals and administer feeding after each meal, adjusting the feeding amount to how much he has eaten.
The nurse is teaching the family how to give tube feedings to the patient prior to discharge. What does the nurse tell them is a common preventable cause of feeding tube obstructions?
Curdled enteral formula
A patient with a pancreatic pseudocyst will require nasojejunal feeding for about 6 weeks. He will need assistance from his wife to administer the feeding. Preparations for discharge should involve which nursing intervention?
Discussing a plan that best fits his lifestyle and including him and his wife in administering his feeding and related care as soon as possible
Which technique is appropriate when caring for a patient who has an NG tube in place for decompression after gastric surgery?
Elevate the head of the bed, unless contradicted.
While preparing the enteral feeding, the nurse should not take which action?
Ensure that the formula is cold
Which intervention should be initiated to decrease the risk of aspiration when a patient is receiving EN?
Ensure that the head of the bed is elevated to at least 30 degrees.
What is the best method of verifying proper feeding tube placement before each medication administration?
Ensure that the tube is in its original taped position
The nurse is preparing to start an enteral feeding through the G tube on a patient who is immunocompromised. Which action should the nurse take first?
Ensure the correct tubing is used
The patient is receiving EN through a continuous open enteral feeding system. How often should the nurse change the system?
Every 4-8 hours
After the feeding tube is confirmed in the proper location and secured, the nurse attempts to take the transmitting stylet out of the feeding tube but is unable to remove it. What is the most appropriate next step?
Flush the tube with 10 ml of water
Leakage around the exit site is observed during assessment of the patient's dressing. What is the best dressing to use in this situation?
Foam dressing
When preparing to insert an NG small-bore feeding tube, how does the nurse measure for the correct depth of insertion?
From the tip of the nose to the earlobe, then from the earlobe to the xiphoid process, plus 10 cm (4 in)
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?
Gagging
When giving more than one medication via a PEG tube, the nurse should follow which procedure?
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?
Gradually over 30-60 minutes
Which technique helps ensure placement of an NG tube into the esophagus and the stomach as opposed to the lung?
Have the patient use the chin-tuck position
A neonate is receiving bolus enteral feedings. The nurse checks the neonate's abdominal girth before starting a feeding and finds that it has increased by 2 cm (0.8 in) from the previous shift and that bowel loops are visible in the neonate's distended abdomen. What should the nurse do next?
Hold the feeding and notify the practitioner
A neonate of 31 weeks' gestation is receiving intermittent tube feedings. Before a feeding, the nurse checks for residual gastric contents and finds 60% of the feeding remaining. The residual contents are green. Which action should the nurse take?
Hold the feeding and notify the practitioner Any contents that are green need to let practitioner know
Which action should be taken before removal of a patient's NG tube?
Insert a small bolus of air into the lumen to clear fluid from the tube. (30 ml)
The nurse is using a small-bore feeding tube for medication administration and encounters a clog in the tube. What should the nurse do next?
Instill warm water and apply a back-and-forth motion
After attempting to flush the patient's enteral tube prior to a feeding, the nurse determines that the tube is clogged. What is the first step to try to unclog the tube?
Instill warm water into the enteral tube and apply a gentle back-and-forth motion with the syringe plunger.
While assessing a patient's bolus tube feeding, the nurse notes that the feeding formula is running very slowly. How should the nurse respond?
Irrigate the feeding tube
The nurse is preparing to administer medications via the feeding tube. What is the appropriate measure to prevent the tube from clogging?
Irrigate the feeding tube with sterile or purified water before, between, and after each medication.
A patient has dysphagia and is receiving tube feeding through a nasogastric tube. What should the nurse do to maintain patency of the nasogastric tube and ensure that the patient is adequately hydrated?
Irrigate the nasogastric tube with sterile or purified water at least every 4 hours and before the first medication, between medications, and after the final medication.
When assisting with the insertion of an enteral feeding tube, the nurse should be prepared to have sutures available for which tube
J tube
When a patient has a risk of aspiration, which type of tube should be used to deliver EN?
Jejunostomy
What is the best way to teach families to connect and disconnect the enteral feeding tube?
Kink the feeding tube while holding it
What should never be used with enteral feeding tubes?
Luer lock syringe
In preparation for an intermittent enteral feeding, the nurse should take which action?
Make sure the formula is at room temperature
Which action should the nurse take to help a patient confirm that the nasoenteric tube has not become displaced before administering a feeding?
Mark the tube where it exits the naris; measure and record the external length in the discharge instructions for comparison.
When assessing a patient who has a new G tube, how does the nurse determine whether the G tube has migrated?
Observe the numeric markings on the tube at the exit site
The patient has an NG tube connected to low constant suction. Which intervention is the most important for assessing proper NG tube function?
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?
Obtaining an x-ray
The nurse is placing a feeding tube in a postsurgical patient. Where should the leading foot of the receiver be placed on this patient?
Over the xiphoid process
Enteral feedings are not indicated for which patients?
Patients who cannot eat for one day because of surgery
To administer a gelcap via an NG tube, the nurse should perform which action?
Pierce the gelcap and empty the contents into purified or sterile water.
The nurse is preparing to irrigate a patient's feeding tube to administer medications. Which action is appropriate to prevent aspiration?
Position the patient in the high-Fowler position
Which intervention is a comfort measure that can ease the discomfort of NG tube insertion?
Provide a focal point for the patient, such as something to hold and squeeze as desired.
What should be done if resistance is encountered during the initial attempt to insert an NG tube?
Pull the tube back slightly and angle it downward
What is an uncommon risk factor for patients with a G tube?
Rectal bleeding
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?
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?
Report the obstruction to the practitioner if the clog remains.
The nurse is inserting a feeding tube in a patient when the tracing veers sharply into the upper right quadrant of the CORTRAK 2 EAS screen. How should the nurse respond?
Retract the feeding tube to erase the track and continue the placement procedure.
A neonate is gavage feeding 20 ml every 3 hours. The nurse is about to feed the neonate and finds 4 ml of partially digested milk remaining in the stomach. What should the nurse do next?
Return the 4 ml of partially digested milk to the neonate's stomach and gavage-feed the neonate.
The nurse checks the GRV of a patient who has a gastrostomy tube and obtains 150 ml. Which action should the nurse take next?
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?
Reverse trendelenburg position
After a small-bore feeding tube is inserted, the nurse and a nursing student discuss the care of the tube with the practitioner. The practitioner sees a dilated stomach on the radiograph. The nurse asks the student what the most appropriate next step should be. The student suggests decompressing the stomach via the tube, thinking that when this problem resolves, the tube can be used for feeding. This suggestion is not appropriate for which reason?
Small-bore feeding tubes are not designed to drain gastric contents.
The nurse is flushing a feeding tube before medication administration. What is the appropriate liquid to use for flushing and medication preparation?
Sterile water
The patient and family should be taught to reconstitute powdered formula with which fluid?
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?
Stomach
During the insertion of a small-bore feeding tube, the patient becomes short of breath and coughs. The nurse identifies a dropping oxygen saturation level and is concerned. Which action should the nurse take?
Stop and retract the tube until the coughing stops and oxygen saturation returns to baseline.
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?
Stop the continuous enteral feeding
A neonate is receiving a continuous feeding at 10 ml/hr. The nurse checks for residual gastric contents before starting the next feeding and obtains 30 ml. What is the most appropriate action?
Stop the feeding and notify the practitioner
An older adult patient is discharged after hospitalization for weight loss because of lung cancer. A nasoenteric tube was placed for enteral feedings to improve his nutrition until surgery next month. The nurse teaches the patient and family that aspiration is a risk with EN when the patient is placed in which position?
Supine For feedings they need to either be sitting upright in a chair, in bed with HOB at 30-45 degrees, or reverse trendelenburg position
A nurse is verifying a practitioner's order for enteral feedings. Which information should be included in the order?
The amount and type of formula or breast milk and the delivery method
The nurse is placing a feeding tube in a comatose patient and knows that in many patients, the pathway through the duodenum resembles a small forward C shape. What is an additional finding that may indicate the tube has entered the duodenum?
The depth indicator drops
A patient is being prepared for NG small-bore feeding tube insertion. At which point during the insertion is the guidewire removed
The guidewire is removed after placement is confirmed via radiographic verification.
A patient's feeding tube stoma site appears reddened. What should the nurse be concerned about, and what action should the nurse take?
The nurse should be concerned that the stoma site is infected and should look for other signs of infection, such as purulent drainage, swelling of the site, and fever.
The nurse is about to begin a gastric enteral feeding. Which patient characteristic would make the nurse stop the process and notify the practitioner?
The patient has an allergy to the formula
A nurse is teaching a new nurse where the various feeding tubes are to be located. Where and how should the J tube be inserted
The second loop of the jejunum through the abdominal wall, typically during a surgical procedure
What does an unexpected change in GRV indicate?
The tube may have moved out of the correct position.
Prior to administering a feeding, what should the nurse do first?
Trace the enteral tubing from the patient to the point of origin.
After the initial placement and confirmation of the distal tip of a small-bore feeding tube, the nurse notices that the tube is no longer secured and that the exit mark is no longer at the nares but is extended 10 cm (4 in) past them. Which set of actions should the nurse take?
Turn off feedings, gently reinsert the tube, and obtain a chest or abdominal radiograph to ensure safe placement of the feeding tube.
The nurse is preparing to insert a feeding tube. What is the most appropriate position to place the patient in for insertion?
Upright with head tipped forward
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?
Using a 30- to 60-ml syringe and warm water, apply a gentle back-and-forth motion to the plunger.
What nursing consideration should be included in the plan of care for a patient who is to begin enteral feeding?
Using directions and examples that are as simple and practical as possible
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?
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?
Verify through radiographic examination.
Which factor may increase the risk of tube displacement?
Vomiting or coughing
Which outcomes should be monitored to assess the adequacy of nutrition in a patient receiving enteral nutrition at home?
Weight trend, energy level, healing, and hunger satisfaction
A nonverbal patient is receiving enteral feedings at home. The family reports that the patient is writhing while enteral feeds are being administered and that the GRV is 550 ml. What should the nurse tell the family member to do
Withhold EN for 2 hours and then recheck the GRV.
The nurse is preparing to aspirate fluid from a nasointestinal tube. The nurse should expect the appearance of the aspirated fluid to be what color?
Yellow
