Lab 10 - Nutrition

A nurse has just inserted a nasogastric tube in a client. Which method is most reliable for verifying the correct placement of the tube? Confirmation that pH of the aspirate is less than 5.5 Radiographic confirmation of position Green fluid with particles aspirated Off-white fluid aspirated

Radiographic confirmation of position

The nurse is using a large syringe to administer an intermittent feeding to a client who has a nasogastric feeding tube. Which method should the nurse use to increase the flow rate of the formula? Attach the syringe to a syringe pump and set the infusion rate to 250 mL/hr. Using the plunger of the syringe, steadily infuse the formula over the desired period of time. Ask the client to bear down while the formula is infusing. Raise the height of the syringe.

Raise the height of the syringe

The nurse is administering an intermittent tube feeding using a gravity set-up and open feeding bag system. At what level should the nurse place the feeding bag on the pole? 12 in (60 cm) above the stomach. 12 in (30 cm) above the stomach. 12 in (30 cm) below the stomach. At stomach level.

12 in (30 cm) above the stomach

The nurse has finished aspirating the gastric contents before administering a prefilled, continuous tube feeding. At this point in the procedure, how much sterile water would the nurse use to flush the tube? 30 mL 40 mL 10 mL 20 mL

30 mL

The nurse is providing a continuous tube feeding for a client. At what angle should the head of the bed be set during the feeding? 90 degrees. 20 to 25 degrees. 30 to 45 degrees. 15 to 20 degrees.

30-45 degrees

A client is receiving a continuous tube feeding. Which accurately describes an aspect of this procedure? The continuous feeding is administered over a 12-hour period. A feeding pump is used for a continuous feeding. The procedure for inserting the tube is different from that for an intermittent feeding. The nurse should check for residual every 8 hours.

A feeding pump is used for a continuous feeding

The nurse prepares to provide gastrostomy insertion site care. The gastrostomy tube was placed this week. The client reports pain at the site. Which action does the nurse take next? Provide for client privacy. Assemble bedside equipment. Clean around the insertion site. Administer pain medication.

Administer pain medication

The nurse is caring for a client who had a percutaneous endoscopic gastrostomy tube inserted earlier in the day. The sutures are still in place. Which interventions should the nurse plan to perform? Select all that apply. Gently clean around the insertion site using a cotton-tipped applicator dipped in sterile saline. Administer prescribed analgesics, as needed. Place a dressing between the skin and external bumper. Measure the length of exposed tube and compare it with the length documented after insertion. Avoid placing tension on the feeding tube. Gently rotate the external bumper 90 degrees once during the shift.

Administer prescribed analgesics, as needed Gently clean around the insertion site using a cotton-tipped applicator dipped in sterile saline. Measure the length of exposed tube and compare it with the length documented after insertion. Avoid placing tension on the feeding tube.

The nurse provides the client with a gravity feeding via a gastrostomy tube. Which action is correct? Assist the client to obtain a desired and comfortable position. Remove and waste gastric residual contents. Allow the feeding to infuse slowly from the feeding bag. Flush the gastrostomy tube with 60 mL of sterile water.

Allow the feeding to infuse slowly from the feeding bag

A nurse is caring for a client with a gastrostomy tube and observes that a large amount of drainage is leaking from the tube. On inspection the nurse finds a great deal of slack in the tube. Which action should the nurse take next? Apply a skin barrier to the insertion site. Gently rotate the external bumper 90 degrees. Notify the health care provider. Apply gentle pressure to the tube while pressing the external bumper closer to the skin.

Apply gentle pressure to the tube while pressing the external bumper closer to the skin.

A nurse enters a client's room to perform a tube feeding. Which nursing action should be performed first? Aspirate stomach contents and check pH. Flush the nasogastric tube with the ordered amount of water. Pour a premeasured amount of tube feeding formula into the nasogastric tube. Check gastric residual.

Aspirate stomach contents and check the pH

A client has had a nasogastric tube inserted in preparation for tube feedings. When developing the client's plan of care, the nurse would anticipate checking the placement of the tube at which time? Every 8 hours during a continuous tube feeding After administering an intermittent tube feeding Before administering a medication through the tube At the beginning of each shift

Before administering a medication through the tube

The nurse is administering an intermittent tube feeding using a gravity set-up and open feeding bag system. After checking tube placement, which action would the nurse take next? Attach the feeding set-up to the feeding tube. Check the residual (the amount of feeding left in the stomach from the last feeding). Flush the tube with sterile water for irrigation. Open the roller clamp and run formula through tubing to purge the air.

Check the residual (the amount of feeding left in the stomach from the last feeding)

The nurse is preparing to administer an intermittent feeding to a client who has a feeding tube. The nurse is unable to aspirate gastric contents and realizes that the tube is clogged. Which action is correct? Advance the tube no more than 4 in (10 cm), auscultate for bowel sounds, and then attempt to aspirate again. Insert a stylet until resistance is felt, and then gently rotate the stylet until resistance decreases. Connect a syringe filled with warm water to the feeding tube and flush it out using gentle pressure. Mix meat tenderizer with 30 mL of warm water, instill the mixture into the feeding tube, wait 15 minutes, and then flush vigorously.

Connect a syringe filled with warm water to the feeding tube and flush it out using gentle pressure.

When monitoring a client with a continuous tube feeding, how often should the nurse confirm placement of the tube? Confirmation that pH of the aspirate is less than 5.5 Radiographic confirmation of position Green fluid with particles aspirated Off-white fluid aspirated

Every 4-6 hours

The nurse is administering an intermittent tube feeding to a client via gravity using an open feeding bag system. What step would the nurse perform when the feeding bag is empty? Aspirate the gastric contents. Remove the bag and tubing and discard. Flush the feeding bag with 30 mL water. Assess the abdomen for bowel sounds.

Flush the feeding bag with 30 mL water

The nurse is caring for a client with a gastrostomy tube and notes a patchy, red rash at the insertion site. Which action would be most appropriate to address this concern? Notify the health care provider for a prescription to apply an antifungal powder. Apply a skin barrier to the insertion site. Apply gentle pressure to the tube while pressing the external bumper closer to the skin. Administer an antibiotic as prescribed.

Notify the health care provider for a prescription to apply an antifungal powder.

The nurse performs gastrostomy site care and notes drainage. What action does the nurse take? Clean the site with hydrogen peroxide. Administer an antibiotic ointment to the site. Notify the health care provider. Place a drain sponge under the external bumper.

Place a drain sponge under the external bumper.

A nurse has just received a client's laboratory results and is reviewing them. Which finding should the nurse recognize as an indication of malnutrition or malabsorption? Creatinine 1.9 mg/dL (168 μmol/L) Hematocrit (Hct) 56% (0.56) Hemoglobin (Hgb) 11.3 g/dL (113 g/L) Serum albumin 2.8 g/dL (28 g/L)

Serum albumin 2.8 g/dL (28 g/L)

Which should the nurse advise the client to do following successful administration of a tube feeding? Sit up for 1 hour. Sit up for 1.5 to 2 hours. Lay flat for 30 to 60 minutes. Ambulate for 20 minutes if not contraindicated.

Sit up for 1 hour.

A nurse aspirates a small amount of fluid from a client's nasogastric tube. The nurse determines that the tube is in the intestines based on the aspirate being which color? Off-white Straw-colored Green Tan

Straw-colored

After inserting a nasogastric tube, what should the nurse do to ensure that the tube is properly placed in the client? Test the pH of aspirated content. Observe for immediate drainage from the tube. Obtain an abdominal ultrasound. Ask about stomach distention and fullness.

Test the pH of aspirated content.

The charge nurse is observing a new nurse care for a client who is receiving a continuous feeding through a nasogastric feeding tube. Which action by the new nurse would require intervention by the charge nurse? The new nurse changes gloves before preparing the feeding bag. The new nurse places the client in the left lateral recumbent position. The new nurse interrupts the feeding every 4 hours and aspirates gastric contents. The new nurse asks the client whether nausea or abdominal pain is present.

The new nurse places the client in the left lateral recumbent position.

When administering a continuous tube feeding using a feeding pump and closed tube feeding system, the nurse plans to check for residual at which frequency? Every 2 to 4 hours. Every 6 to 8 hours. Every 4 to 6 hours. Every 1 to 2 hours.

every 4-6 hours