Nutrition and nasogastric tube placement

To honor cultural values of patients from different ethnic/religious groups, which actions demonstrate culturally sensitive care by the nurse? (Select all that apply.)

-allows fasting on Yom Kippur for a Jewish patient -serves no ham products to a Muslim patient -Serves no meat or fish to a Hindu patient

The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take?

-wear a sterile mask when changing the central venous catheter dressing

A nurse is preparing to administer an enteral feeding. In which order will the nurse implement the steps, starting with the first one?1. Elevate head of bed to at least 30 degrees.2. Check for gastric residual volume.3. Flush tubing with 30 mL of water.4. Verify tube placement.5. Initiate feeding.

1,4,2,3,5

The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. Which action is best for the nurse to take?

Check with the pharmacy for availability of the liquid forms of medications.

The nurse is assessing a patient for nutritional status. Which action will the nurse take?

Combine multiple objective measures with subjective measures.

The patient has been diagnosed with Helicobacter pylori. The nurse should encourage which action initially?

completion of antibiotic therapy

The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient's skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide?

drink more water to prevent further dehydration

A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient?

flex head and chin down

The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the most likely cause of the diarrhea?

formula intolerance

The nurse is preparing to insert a nasogastric tube. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?

from the tip of the nose to the earlobe to the xiphoid process

Before giving the patient an intermittent gastric tube feeding, what should the nurse do?

have the tube feeding at room temperature

The patient is admitted with facial trauma, including a broken nose, and has a history of esophageal reflux and of aspiration pneumonia. With which tube will the nurse most likely administer the feeding?

jejunostomy tube

The nurse is planning care for a group of stable patients. Which task will the nurse assign to the nursing assistive personnel?

measuring capillary blood glucose level

The patient has a calculated body mass index (BMI) of 34. How will the nurse classify this finding?

obesity

The patient has just started on enteral feedings, and is now reporting abdominal cramping. Which action will the nurse take next?

slow the rate of tube feeding

Which assessment finding is consistent with the diagnosis of malnutrition?

spoon-shaped nails

Which patient diagnosis increases the risk for developing neurogenic dysphagia?

stroke

A patient develops a foodborne disease from Escherichia coli. When taking a health history, which food item will the nurse most likely find the patient ingested?

undercooked ground beef

The nurse is concerned about pulmonary aspiration when providing care to the patient with an intermittent tube feeding. Which action is the priority?

verify tube placement before feeding

A small-bore feeding tube is placed. Which technique will the nurse use to best verify tube placement?

x-ray