Clinical Nursing Skills Nutrition

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. 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.

Connect a syringe filled with warm water to the feeding tube and flush it out using gentle pressure. Rationale:Most obstructions are caused by coagulation of formula. The nurse should try using warm water and gentle pressure to remove the clog. Carbonated sodas, such as Coca-Cola, and meat tenderizers have not been shown effective in removing clogs in feeding tubes. Never use a stylet to unclog tubes. Advancing the tube is not needed, as this will not address the clog.

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 20 mL 40 mL 10 mL

30 mL Rationale:Following aspiration of the gastric contents, the nurse would use 30 mL of sterile water to flush the tube. Water rinses the feeding from the tube and keeps it patent.

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

A feeding pump is used for a continuous feeding. Rationale:A continuous tube feeding is administered over a 24-hour period and a feeding pump is always used. The nurse would check for residual every four to six hours. Regardless of the type of tube used, the procedure for tube insertion is the same.

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. Administer pain medication. Assemble bedside equipment. Clean around the insertion site.

Administer pain medication. Rationale:Gastrostomy feeding tubes are uncomfortable for the first days after insertion. The client will tolerate site care better after analgesic administration. While waiting for the medication to take effect, the nurse can prepare the area. After the medication is working, the nurse provides for privacy and begins site care, carefully assessing for other reasons for site pain including excessive erythema or edema.

Prior to allowing a client to eat, which action is most important for the nurse to take? Assess the client's level of consciousness. Determine if the client has physical limitations. Determine if the client has eye glasses. Check for the client's cultural preferences.

Assess the client's level of consciousness. Rationale:The most important thing the nurse can do is to ensure the client is alert enough to safely eat without aspirating. Next, ensuring the client is physically able to self-feed and safely swallow is necessary. The client's cultural needs and eye sight are least important.

The client with dysphagia has a regular meal tray delivered at breakfast. Which is the best action for the nurse to take? Replace the client's meal tray with soft foods available on the unit. Chop the client's food to make it easier to swallow. Offer the client a sip of liquid in between each bite. Check the medical record for the client's prescribed diet.

Check the medical record for the client's prescribed diet. Rationale:The nurse ensures the client has gotten the correct meal tray. Often a client on a dysphagia diet will have a special diet that includes softer or pureed foods and thickened liquids that aren't available on the regular diet tray. The other actions are not incorrect, but the client may not be on a chopped food diet. Sometimes the client with dysphagia just requires sips between bites, and there is no reason to use foods from the unit's kitchen area. The best action the nurse can take is to ensure the client get the correct meal tray.

A nurse is caring for a client who has been prescribed a clear liquid diet. Which liquid can be included in the client's diet? Low-fat milk Orange juice Tomato soup Cranberry juice

Cranberry juice Rationale:Composed only of clear fluids or foods that become fluid at body temperature and includes clear broth, coffee, tea, clear fruit juices (apple, cranberry, grape), gelatin, popsicles, commercially prepared clear liquid supplements. A clear liquid diet requires minimal digestion and leaves minimal residue. Low-fat milk, fruit juices or soup, and juices with fruit pulp (orange and grapefruit) are considered full-liquid diet.

When monitoring a client with a continuous tube feeding, how often should the nurse confirm placement of the tube? Every 24 hours. Every shift. Every 4 to 6 hours. Every 2 to 4 hours.

Every 4 to 6 hours. Rationale:The nurse would confirm the tube placement for a client receiving a continuous tube feeding every 4 to 6 hours. Checking placement verifies that the tube has not moved out of the stomach.

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? Hematocrit (Hct) 56% (0.56) Serum albumin 2.8 g/dL (28 g/L) Hemoglobin (Hgb) 11.3 g/dL (113 g/L) Creatinine 1.9 mg/dL (168 μmol/L)

Serum albumin 2.8 g/dL (28 g/L) Rationale:Normal serum albumin is 3.3 to 5 g/dL (33 to 50 g/L). Decreased albumin indicates malnutrition or malabsorption. Decreased Hgb indicates anemia. Increased creatinine indicates dehydration. Increased Hct indicates dehydration.

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

Sit up for 1 hour. Rationale:After administering a tube feeding, the nurse should have the client sit up for at least 30 minutes to one hour to minimize risk for backflow or aspiration if any reflux or vomiting should occur.

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? 24 in (60 cm) above the stomach. At stomach level. 12 in (30 cm) below the stomach. 12 in (30 cm) above the stomach.

12 in (30 cm) above the stomach. Rationale:The nurse would hang the feeding bag 12 in (30 cm) above the stomach. Proper feeding bag height reduces the risk of formula being introduced too quickly.

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. 15 to 20 degrees. 30 to 45 degrees. 20 to 25 degrees.

30 to 45 degrees. Rationale:During the administration of a continuous tube feeding, the head of the bed should be elevated at 30 to 45 degrees. This position minimizes possibility of aspiration into the trachea. Clients considered high risk for aspiration should be assisted to at least a 45-degree position.

Arrange the answers into the correct order by dragging the unordered answers from left to the right section. Mouse users arrange by clicking and dragging each answer to the desired location. Keyboard users can arrange by traversing through arrows provided. The nurse is preparing to administer an intermittent feeding to a client who has a nasogastric feeding tube. Place the following steps in the correct order. Use all options.

4The nurse is preparing to administer an intermittent feeding to a client who has a nasogastric feeding tube. Place the following steps in the correct order. Use all options. Time spent - 00:03:25 Your Response: 1)Position the client with the head of bed elevated 30 to 45° degrees. 2)Verify correct tube placement. 3)Aspirate all gastric contents. 4)Administer the feeding. 5)Verify that residual volume is less than 200 mL. 6)Flush the tube with 30 mL of water. Correct Response: 1)Position the client with the head of bed elevated 30 to 45° degrees. 2)Verify correct tube placement. 3)Aspirate all gastric contents. 4)Verify that residual volume is less than 200 mL. 5)Flush the tube with 30 mL of water. 6)Administer the feeding. Rationale:Elevating the head of the bed 30 to 45° degrees minimizes the possibility of aspiration into the trachea. Verifying correct tube placement ensures that the formula is being delivered to the stomach appropriately. The nurse should aspirate all gastric contents with the syringe and measure to check for gastric residual, the amount of feeding remaining in the stomach from the previous feeding. This is done to identify delayed gastric emptying. High gastric residual volumes (200 to 250 mL or greater) can be associated with high risk for aspiration and aspiration-related pneumonia, so feedings should be held if residual volumes exceed 200 mL on two successive assessments. Flushing the tube prevents occlusion.

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

Allow the feeding to infuse slowly from the feeding bag. Rationale:The nurse allows the gravity feeding to infuse over about 30 minutes from the feeding bag. The tube is flushed before and after feedings with 30 mL of tap water. Gastric contents are replaced unless there is a large quantity according to institution policy. The nurse does assist the client to be comfortable, but the client must stay in an upright position for approximately 1 hour after feeding for safety.

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. Notify the health care provider. Apply gentle pressure to the tube while pressing the external bumper closer to the skin. Gently rotate the external bumper 90 degrees.

Apply gentle pressure to the tube while pressing the external bumper closer to the skin. Rationale:If there is a large amount of slack between the internal guard and the external bumper, drainage can leak out of the site. In this case, the nurse should apply gentle pressure to tube while pressing the external bumper closer to the skin. Although the nurse should gently rotate the external bumper 90 degrees at least once a day, this action would not address the leaking of the tube. Skin barrier should be applied to protect the skin from irritation by the tube; however, this action would not address the leaking, either. There is no need to notify the health care provider regarding this issue.

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 pH. Rationale:Nasogastric tube placement should be checked before flushing, giving medications, or feeding. After placement has been ensured, the gastric residual should be checked, the nasogastric tube should be flushed as ordered, and the tube feeding administered.

A nurse delivers a tray of food to an older client and sets it on the overbed table. The client shows no interest in the food, however. Which actions should the nurse take? Select all that apply. Assess the client for signs of depression. Administer an antiemetic as prescribed. Consult a dietician if the problem persists. Remove the tray from the client's room without further comment. Provide the client with crackers and ginger ale. Ask why the client does not want to eat anything on the tray.

Assess the client for signs of depression., Consult a dietician if the problem persists., Ask why the client does not want to eat anything on the tray. Rationale:The nurse should explore with the client the reason why he does not want to eat anything on the tray. The nurse should assess for psychological factors that impact nutrition. Malnutrition is sometimes found with depression in the older adult population. The nurse and client should mutually develop a plan to address the lack of nutritional intake and consult the dietitian as needed. The nurse should not remove the tray until the reason for the client's not eating is explored. Crackers and ginger ale may be offered and an antiemetic administered if nausea is the reason for the lack of eating, but this is not established.

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 rotate the external bumper 90 degrees once during the shift. Avoid placing tension on the feeding tube. Place a dressing between the skin and external bumper. Administer prescribed analgesics, as needed. Measure the length of exposed tube and compare it with the length documented after insertion. Gently clean around the insertion site using a cotton-tipped applicator dipped in sterile saline.

Avoid placing tension on the feeding tube., Measure the length of exposed tube and compare it with the length documented after insertion., Gently clean around the insertion site using a cotton-tipped applicator dipped in sterile saline., Administer prescribed analgesics, as needed. Rationale:Feeding tubes can be uncomfortable, especially the first few days after insertion. Analgesic medication may permit the client to tolerate the insertion site care more easily. Cleansing the new site with sterile saline solution helps prevent infection. Measuring the tube assures that the tube has not migrated. Avoiding placing tension on the tube helps prevent skin breakdown. Rotating the external bumper 90 degrees should be done after sutures have been removed. A dressing should be used only if drainage is present; otherwise, it should be left open to the air.

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? After administering an intermittent tube feeding Before administering a medication through the tube Every 8 hours during a continuous tube feeding At the beginning of each shift

Before administering a medication through the tube Rationale:The nurse would verify correct placement of the nasogastric tube after the initial insertion, before beginning a feeding or instilling medications or liquids, and at 4-hour intervals during continuous feedings. This ensures that the tip of the tube is situated in the stomach or intestine, preventing inadvertent administration of substances into the wrong place. A misplaced feeding tube in the lungs or pulmonary tissue places the client at risk for aspiration.

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. 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). Flush the tube with sterile water for irrigation.

Check the residual (the amount of feeding left in the stomach from the last feeding). Rationale:After checking for tube placement, the nurse would check for the residual and then flush the tube with 30 mL of sterile water. If the residual amount does not exceed agency policy or the limit indicated in the medical record, then the nurse would proceed with the feeding.

A client with dysphagia prepares to eat dinner. How does the nurse best help this client? Prepare the foods on the client's tray. Play the client's favorite music or video. Ensure the head of the bed is high-Fowler. Converse with the client during the meal.

Ensure the head of the bed is high-Fowler. Rationale:The nurse must ensure that the client is sitting up well enough to safely eat, whether that is high-Fowler or in the chair. The nurse may assist in setting up the meal tray or play something the client enjoys for background noise. The client with dysphagia should have minimal conversation while eating due to the increased risk of failure to correctly swallow.

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 1 to 2 hours. Every 6 to 8 hours. Every 2 to 4 hours. Every 4 to 6 hours.

Every 4 to 6 hours. Rationale:When administering a continuous tube feeding, the nurse would check for residual every 4 to 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? Remove the bag and tubing and discard. Assess the abdomen for bowel sounds. Flush the feeding bag with 30 mL water. Aspirate the gastric contents.

Flush the feeding bag with 30 mL water. Rationale:When the feeding bag is empty, the nurse would flush the feeding bag with 30 mL water to flush out the bag itself and the feeding tube at the same time. The nurse would then clamp the tubing when the water is instilled.

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

Radiographic confirmation of position Rationale:Radiographic (x-ray) examination is the only reliable method to determine accurate tube placement. In the absence of an x-ray, pH testing is predicative of correct placement. Although visualization of aspirated contents can help confirm correct placement of the tube, this method is not as reliable as an x-ray.

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? Apply a skin barrier to the insertion site. Notify the health care provider for a prescription to apply an antifungal powder. Administer an antibiotic as prescribed. Apply gentle pressure to the tube while pressing the external bumper closer to the skin.

Notify the health care provider for a prescription to apply an antifungal powder. Rationale:If the skin has a patchy, red rash, the cause could be candidiasis (yeast). The nurse should notify the health care provider for a prescription to apply an antifungal powder. Applying gentle pressure to the tube while pressing the external bumper closer to the skin is performed when there is slack between the external bumper and the internal guard, resulting in leaking from the tube. An antibiotic would not be indicated for treating candidiasis. A skin barrier should be applied to protect the skin from irritation by the tube; however, this action would not address candidiasis, either.

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. Rationale:When the nurse notes drainage, a precut sponge or gauze is placed around the tube for comfort and to prevent irritation. Drainage is a normal finding. The health care provider is notified if the drainage has an odor, appears infected, or looks like the feeding solution being administered. Gastrostomy sites are no longer cleansed with hydrogen peroxide as this disrupts healing. Antibiotic ointments have not been found to be useful and are not used.

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? 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. Attach the syringe to a syringe pump and set the infusion rate to 250 mL/hr.

Raise the height of the syringe. Rationale:Syringe feedings are infused via gravity. Raising the syringe will increase the rate of infusion. Syringe pumps are used for IV infusions rather than gastric feeding. Feeding through a syringe should be done by gravity, not by positive pressure using the plunger. The client bearing down will likely have little effect on the rate of infusion.

The nurse is caring for a client who has dysphagia and is unable to eat independently. The nurse is preparing to assist the client in eating a meal. Which action is appropriate? Arrange food items in a clock face pattern and inform the client which time on a clock corresponds to each food item. Speak to the client but limit the need for the client to respond verbally while chewing and swallowing. Create a positive social environment by asking the client about childhood food memories. Encourage the client to eat using a consistent, efficient pace to prevent hot foods from becoming too cool and cool foods from becoming too warm.

Speak to the client but limit the need for the client to respond verbally while chewing and swallowing. Rationale:Talking during eating increases the risk of aspiration for a client who has dysphagia. Arranging food on the plate in a clock face pattern is a strategy appropriate for a client who is visually impaired. Clients who have dysphagia need to eat slowly and be continually observed for signs of aspiration. Allow enough time for the client to adequately chew and swallow the food. The client may need to rest for short periods during eating.

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? Green Tan Off-white Straw-colored

Straw-colored Rationale:Gastric fluid can be green with particles, off-white, or brown if old blood is present. Intestinal aspirate tends to look clear or straw-colored to a deep golden yellow color. Also, intestinal aspirate may be greenish brown if stained with bile. Respiratory or tracheobronchial fluid is usually off-white to tan and may be tinged with mucus.

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

Test the pH of aspirated content. Rationale:Current research demonstrates that the use of pH is predictive of correct placement of a nasogastric tube. The pH of gastric contents is acidic (less than 5.5). If the client is taking an acid-inhibiting agent, the range may be 4.0 to 6.0. The pH of intestinal fluid is 7.0 or higher, indicating the tube is beyond the stomach. The pH of respiratory fluid is 6.0 or higher. An x-ray can also be used to check placement of the tube, as well as aspirating the gastric contents and checking them for color and consistency. A feeling of fullness will not confirm tube placement. An ultrasound is not used for confirmation of tube placement

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 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 changes gloves before preparing the feeding bag. The new nurse places the client in the left lateral recumbent position.

The new nurse places the client in the left lateral recumbent position. Rationale:The client's head should be elevated 30 to 45 degrees. All of the other actions are correct and would not require intervention by the charge nurse.