NU 311 exam 4 ENTERAL FEEDING

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

*A* Coughing. Correct *B*Choking. Correct *C* Decreased pulse oximetry. Correct

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.

*A.* Dyspnea and decreased oxygen saturation. Correct

The nurse is going to administer an intermittent tube feeding. Because the patient's feeding tube has been in place for 3 days, which action is best for the nurse to take at this time?

Aspirate gastric contents and test on a pH strip. ****Ongoing verification of tube placement is made by pH testing of aspirate. Verification by x-ray film is necessary on feeding tube insertion and if tube migration is suspected. Auscultation is no longer considered a reliable method for determining feeding tube placement. The tube can migrate without moving at its externally taped location.

Which of the following patients may benefit from enteral nutrition? *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. *E.* A patient who had a CVA (stroke) and has dysphagia (difficulty swallowing).

*A.* A patient who has a brain injury. Correct *B.* A patient with oral cancer. Correct *D.* A patient with burns of the lower extremities. Correct *E.* A patient who had a CVA (stroke) and has dysphagia (difficulty swallowing).

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

*A.* On the patient's right side Correct

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.* Position patient on side. *D.* Contact health care provider for possible chest x-ray. *E.* Have patient sip ice water.

*A.* Suction airway as needed. Correct *C.* Position patient on side. Correct *D.* Contact health care provider for possible chest x-ray. Correct

The health care provider has ordered an enteral feeding tube for an elderly patient. Which statement, if made by the patient's family member, indicates further instruction is needed? *A.* "The enteral feedings will help provide additional calories." *B.* "The tube feedings are used to improve digestion." *C.* "This will help prevent her from getting pneumonia again from choking." Incorrect *D.* "Tube feedings are less likely to cause infection than getting nutrients by IV infusion."

*B.* "The tube feedings are used to improve digestion."

The nurse is inserting an NG feeding tube for the first time. Which action, if made by the nurse, indicates further instruction is needed? *A.* The nurse dips the end of the tube into a glass of water to activate the lubricant. *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.

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

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. The pH strip reads "3." Where should the nurse expect the x-ray film to identify placement of the feeding tube? *A.* In the lungs. *B.* In the esophagus. *C.* In the stomach. *D.* In the small intestine.

*C.* In the stomach. Correct

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.

*D.* Aspiration.

Sequence the procedure for verifying feeding tube placement.

1. *Perform hand hygiene*. Apply clean gloves. Draw up 30 mL of air into ENFit syringe, then attach to end of feeding tube. Flush tube with 30 mL of air. 2. *Draw back on syringe and obtain 5 to 10 mL of gastric aspirate.* Observe appearance of aspirate. 3. *Measure pH of aspirate.* Compare the color of the strip with the color on the chart provided by the manufacturer. 4. *Discard* used supplies, remove gloves and discard, and perform hand hygiene.

What activates lubricant to facilitate passage of tube into GI tract?

Dip tube with surface lubricant into a glass of water

What ensures tube patency and aids in guide wire or stylet insertion?

Inject 10 mL of water from 30-mL or larger syringe into the feeding tube

Which of the following is an appropriate nursing action to prevent a complication of nasogastric (NG) tube feedings?

Keep the head of the patient's bed elevated at least 30 degrees. ***Head of bed elevation to a minimum of 30 degrees is a simple method to keep the risk for aspiration at a minimum. The nurse is instrumental in achieving this goal. To prevent air from entering stomach between feedings, clamp or plug end of tube when feeding is absent. The nurse should refill the syringe before it is completely empty until prescribed amount has been administered. Use a new administration set every 24 hours for an open system.

What determines approximate depth of insertion

Measure distance from tip of nose to earlobe to xyphoid process of sternum and mark tube with tape or indelible ink

If the nurse suspects the NG feeding tube has migrated, the nurse should:

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

A nursing instructor is reviewing the skill of irrigating a feeding tube with a group of nursing students. Which statement(s), if made by the nursing student, is(are) accurate, indicating learning has occurred? (Select all that apply.) *A.* "Curdled enteral formula and improperly crushed medications are the most common causes of feeding tube occlusion." *B.* "It is unnecessary to irrigate a feeding tube if the patient's medications are in liquid form." *C.* "It is acceptable to delegate routine irrigation of a feeding tube to NAP." *D.* "It is unnecessary to irrigate nasoenteric feeding tubes; only nasogastric tubes require irrigation." *E.* "Bowel sounds should be present if the patient is receiving tube feedings." *F.* "The patient should be placed in a high Fowler's or semi-Fowler's position for feeding tube irrigation."

*A.* "Curdled enteral formula and improperly crushed medications are the most common causes of feeding tube occlusion." Correct *E.* "Bowel sounds should be present if the patient is receiving tube feedings." Correct *F.* "The patient should be placed in a high Fowler's or semi-Fowler's position for feeding tube irrigation." Correct

The nurse observes a confused patient pulling at her NG feeding tube. As the nurse retapes the tube to the bridge of the patient's nose, the nurse notices that the mark on the tube has moved away from the naris. What action should the nurse 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.

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

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.* Immediately after administration of medications through the feeding tube. *E.* Upon discontinuing the feeding tube.

*A.* Before each intermittent feeding. Correct *B.* At least once every 6 hours during continuous feedings. Correct *C.* Before administration of medications through the tube. Correct

A nurse is reviewing the policy for irrigating a feeding tube. What information should the nurse include that would address accurate principles of infection control when performing this procedure? (Select all that apply.) *A.* Change irrigation bottle every 24 hours. *B.* Use only sterile water for irrigation. *C.* Perform hand hygiene and apply clean gloves to irrigate a feeding tube. *D.* Tap water should not be used for feeding tube irrigation with neonates. *E.* Sterile water may be required for patients who are critically ill.

*A.* Change irrigation bottle every 24 hours. Correct *C.* Perform hand hygiene and apply clean gloves to irrigate a feeding tube. Correct *D.* Tap water should not be used for feeding tube irrigation with neonates. Correct *E.* Sterile water may be required for patients who are critically ill. Correct

Enteral feedings may be administered by: (Select all that apply.) *A.* Continuous feeding pump. Correct *B.* Through a large vein. *C.* Intermittent gravity drip. Correct *D.* Through a central vascular access device. *E.* Intravenously.

*A.* Continuous feeding pump. *C.* Intermittent gravity drip.

The patient is presently receiving intermittent tube feedings of 120 mL every 6 hours. The health care provider'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 500 mL.

*A.* Diarrhea. Correct *B.* Abdominal distention and discomfort. Correct *C.* Nausea. Correct *F.* Residual volume greater than 500 mL.

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." Correct *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." Incorrect *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."

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

The nurse is going to irrigate a nasogastric feeding tube. The nurse would be correct to draw up how much water into the ENFit syringe? *A.* 15 mL. *B.* 30 mL. *C.* 60 mL. *d.* The same amount as the gastric residual volume.

*B.* 30 mL. Correct

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.

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

The nurse understands that irrigating a feeding tube helps prevent it from becoming clogged and clears the tubing of fluid. At what times is it appropriate to flush a feeding tube? (Select all that apply.) *A.* Once a shift. *B.* Before medication administration. *C.* Before an intermittent feeding. *D.* Between medications. *E.* After medication administration.

*B.* Before medication administration. *C.* Before an intermittent feeding. *D.* Between medications. *E.* After medication administration.

The health care provider 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.* Gastric aspirate is expected to have a lower pH than intestinal aspirate. *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. *D.* Both NG and NI tubes are usually used for less than 30 days.

*B.* Gastric aspirate is expected to have a lower pH than intestinal aspirate. Correct *C.* The advantage to an NI tube is that there is less risk for aspiration. Correct *D.* Both NG and NI tubes are usually used for less than 30 days.

A patient is receiving a continuous enteral feeding by infusion pump. The nurse enters the patient's room to verify tube placement and measure residual. The nurse notices the patient's respirations are shallow and rapid and that the patient's color is ashen. The nurse notes crackles on auscultation, and the patient appears to be coughing up sputum of a color similar to the formula feeding. What action(s) should the nurse take? (Select all that apply.) *A.* Ask if the patient feels short of breath. *B.* Position patient on side. *C.* Turn off the tube feeding. *D.* Have the patient deep breathe and cough. *E.* Suction the patient. *F.* Notify the health care provider.

*B.* Position patient on side. Correct *C.* Turn off the tube feeding. Correct *E.* Suction the patient. Correct *F.* Notify the health care provider. Correct ***The patient has aspirated formula. The nurse should turn off the tube feeding immediately, position the patient in in a side-lying position, suction, and notify the health care provider. It is unnecessary to ask the patient about feeling short of breath because it is apparent. Having the patient deep breathe and cough will fail to help at this time.

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 into the posterior nasopharynx and attempt to reinsert. *C.* Instruct the patient to take small sips of water and swallow. *D.* Auscultate over the carina.

*B.* Pull the tube back into the posterior nasopharynx and attempt to reinsert. Correct

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."

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

A nurse is telling a coworker that she is unable to flush a feeding tube. Which suggestion offered by the coworker would be accurate, useful information? *A.* Try using Coca-Cola to flush the tubing; the carbonation will break up any blockage." *B.* "Cranberry juice works well because the acidity dissolves occlusions from medication." *C.* "Call the health care provider; the tube is going to have to be replaced." *D.* "Reposition the patient and see if you are able to flush the tubing with water."

*D.* "Reposition the patient and see if you are able to flush the tubing with water."

The nurse is irrigating a nasogastric feeding tube after having verified tube placement by pH testing. The nurse draws up 30 mL of tap water into an ENFit syringe, removes the plug at the end of the tube, attaches the ENFit syringe, and slowly instills the irrigation solution. The nurse removes the syringe and plugs the end of the tube. What error occurred in the performance of this skill? *A.* There was no error; the nurse performed the skill correctly. *b.* The nurse failed to kink the tubing before connecting and removing the syringe from the end of the feeding tube. *C.* The nurse should have used sterile water from a container marked with the date and nurse's initials. *D.* The nurse instilled the irrigation solution at an incorrect rate.

*b.* The nurse failed to kink the tubing before connecting and removing the syringe from the end of the feeding tube. Correct

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.* Nasotracheal suctioning. *e.* Altered level of consciousness, agitation. *f.* H2 antagonists.

*c.* Vomiting. Correct *d.* Nasotracheal suctioning. Correct *e.* Altered level of consciousness, agitation. Correct

PH of stomach of fasted person

1-5

PH of Intestine of fasting patient.

6 or greater

PH of Pleural fluid from tracheobronchial tree.

6 or greater

Why is it important to have the tube feeding at room temperature?

Cold formula can cause gastric cramping.

The patient is receiving a continuous enteral feeding. Which of the following assessment findings would require follow-up?

Gastric residual of 375 mL. ***GRVs in range of 200 to 500 mL should raise concern and lead to implementation of measures to reduce risk of aspiration. Normal residual for a nasoenteric tube is in the 10 mL or less range. Bowel sounds in all four quadrants and pH of 5.0 in gastric contents is normal for a patient who is receiving continuous enteral feeding.

What closes off glottis and reduces risk of tube entering trachea?

Have patient flex head toward chest after tube has passed through nasopharynx

What facilitates passage of tube past oropharynx; rotation decreases friction?

Have patient mouth breathe and swallow. Give small sips of water or ice chips when possible. Advance tube as patient swallows. Rotate tube 180 degrees while inserting

The nurse is going to irrigate the patient's established feeding tube with 30 mL of tap water before instilling the tube feeding. The nurse attempts to do so without success. What should action should the nurse take?

Reposition the patient. ***The nurse should first reposition the patient on the left side and try again. The tip of the tube may be lying against the stomach wall. Changing the patient's position may move the tip away from the stomach wall. The nurse may attempt to flush the tubing with a large-bore syringe and warm water. If still unable to clear the feeding tube, the health care provider should be notified. Baking soda or cola should never be used because they could cause further complications if aspirated.

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?

Return the aspirate to the patient's stomach and administer the feeding. ***These are normal findings. The nurse should return the gastric aspirate to the patient's stomach to prevent an alteration in electrolyte balance and administer the tube feeding as prescribed.