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Terms in this set (90)
the rights the nurse should implement to enhance safety for a patient who is prescribed enteral feedings?
the right tube,
patient,
formula, and
ENFit adaptor.
The right dose, not enteral tube feeding administration, is a right of medication administration.
nursing action is inappropriate when checking for gastric residual volume (GRV) before each enteral feeding?
Discarding gastric contents
(leads to fluid and electrolyte imbalances )
nursing action is appropriate when checking for gastric residual volume (GRV) before each enteral feeding?
Flushing the tube with 30 mL of air, administering the feeding for a gastric volume of 425 mL, and pulling back slowly to aspirate the total volume of gastric contents
assessing a patient prior to insertion of an enteral feeding tube, which finding should alert the nurse to poor nutrition?
Enlarged spleen
indicate good nutrition
Moist lips, shiny hair, and a smooth tongue
assessment finding should the nurse report to the health care provider for a patient who is prescribed aspiration precautions?
choking,
gagging,
coughing, and
difficulty swallowing.
All of these findings could indicate the patient has aspirated.
Until radiographic confirmation of placement of an intestinal tube is completed, in which position should the nurse place the patient after intubation?
right side-lying position
after intubation of an intestinal tube until radiographic confirmation takes place because this positioning promotes passage of the tube into the small intestine.
Which complication may occur if the nurse were to add food coloring to the formula for a patient who is prescribed enteral feeding?
Hypotension
It can, however, also cause metabolic acidosis.
Which assessments should the nurse perform prior to inserting a nasoenteric tube for enteral feedings?
height,
weight, and
hydration status.
provides baseline information to measure nutritional improvement after enteral feedings are initiated.
Which information should the nurse include on the label of an enteral feeding to promote patient safety?
date
time
the formula is hung,
the patient's name,
the rate of the feeding,
patient's room number
Which nursing action is appropriate when planning to intubate a patient with a prescribed feeding tube?
Explaining the sensations that are expected
may auscultate the patient's bowel sounds, but it is not necessary for intubation.
Which data should nurse document in the patient's medical record after the intubation of an enteral tube?
type
size of tube inserted,
pH value of the gastric aspirate, confirmation of tube placement by x-ray film.
The location of the distal, not proximal, end of the tube should also be documented.
In which position should the nurse place the patient to conduct blood glucose monitoring?
semi-Fowler's position when conducting blood glucose monitoring
Which skill should the nurse delegate to nursing assistive personnel when providing care to a patient receiving enteral feedings?
Positioning the patient during insertion
Which piece of equipment should the nurse have available to remove a small-bore nasoenteric tube for a patient whose enteral feedings have been discontinued?
oral hygiene
quipment required to insert, not remove, a small-bore nasoenteric tube.
An emesis basis,
tongue blade,
30-mL Luer-Lock catheter tip syringe
equipment should the nurse have available when testing a patient's blood glucose level?
lancet,
paper towel,
antiseptic swab available.
Clean, not sterile, gloves
Which nursing action is appropriate for a patient with a gastric aspirate of 150 mL?
Return all the aspirate
How often should the nurse change the feeding bag for a patient who is prescribed an intermittent enteral feeding?
Every day
Which equipment should the nurse have available when assessing the pH of gastric aspirate?
Test paper
(paper towel , CLEAN gloves , SMALL medication cup )
The nurse is providing care to a patient who has reached the maximum administration rate for the prescribed enteral feedings. How often should the nurse weigh the patient based on the current data?
Three times per week
Weighing the patient daily is done ?
done until the maximum administration rate is achieved.
Which are possible causes for constipation in a patient who is prescribed enteral tube feedings?
Lack
of fiber in the diet
Inactivity
may cause diarrhea, in a patient who is prescribed enteral tube feedings?
Malabsorption,
too much free water,
bacterial contamination
Which nursing action is appropriate prior to administering a nasoenteric feeding?
Assessing capillary blood glucose
Which nursing actions are appropriate when obtaining gastrointestinal (GI) aspirate for pH measurement in a patient who is prescribed continuous tube feedings?
Drawing 30 mL of air into the syringe (to check placement )
Planning the test after chest physiotherapy
Checking tube placement every 4 to 6 hours
X-ray is used to verify ?
placement prior to the first feeding and whenever the tube's placement is questioned, but not on a regular weekly basis
The nurse should wait to complete this procedure
60 mins after med administration
Which nursing action is appropriate when providing care to a patient whose enteral feeding tube is clogged?
use pancreatic enzymes to unclog the tube
A dietician should be consulted
if the patient develops diarrhea three times in a 24-hour period but not for a patient who has a clogged feeding tube.
Which is the priority nursing action when intubating a patient with a feeding tube?
Verifying the health care provider's order
Which patient behaviors should the nurse instruct nursing assistive personnel (NAP) to report during the administration of an enteral feeding?
any patient discomfort
choking,
gagging, and
coughing,
because these may indicate that the patient has aspirated
Which nursing actions are appropriate when checking for gastric residual volume (GRV) before each enteral feeding?
Flushing
the tube with 30 mL of water
Holding the feeding for an aspirate volume of 525 mL
Pulling back slowly to aspirate total volume of gastric contents
flush the tube with 10 to 30 mL of air
Which nursing action is appropriate when providing care to a patient who is prescribed intermittent tube feedings?
Checking tube placement prior to each feeding
continusous tube feedings, Tube placement is monitored ?
every 4 to 6 hours for patients who are prescribed continuous, not intermittent, tube feedings. The tube is flushed with 30 mL of water to avoid clogging.
Which actions should the nurse implement when feeding a patient who is prescribed aspiration precautions?
Telling the patient to open his or her mouth
Encouraging the patient
to feel the food in his or her mouth
Asking the patient to cough in order to clear the airway
Teaching the patient to raise his or her tongue to the roof of the mouth when eating
Which nursing action supports safety guidelines that are essential when providing care to a patient who is receiving a tube feeding?
Allowing the open formula system to hang for no more than 8 hours
Medical, not surgical,
aseptic technique
head of the patient's bed should be placed at 30 to 45 degrees, not 90
determine the length of the tube needed for a nasointestinal (NI) intubation?
Adding an additional 20 to 30 cm (8 to 12 in) to the measured length of the tube
The nurse is administering an enteral feeding to a patient who must remain in a supine position. Which nursing action is appropriate?
Placing the patient in reverse Trendelenburg's position
(person is lying supine with the head elevated higher than the rest of the body and the feet supported with a foot board.)
Which nursing action is appropriate when providing care to a patient who experiences pulmonary aspiration due to enteral feedings?
Suctioning the airway
Which nursing action prevents gastric cramping and discomfort during a nasoenteric feeding?
Warming the patient's formula to room temperature
(Cold formula causes gastric cramping and discomfort because the mouth and esophagus cannot warm the liquid)
feeding a patient with dysphagia. Which position of the patient should be avoided to reduce the risk of aspiration?
Supine
Which nursing action is appropriate when providing care to a patient who is prescribed aspiration precautions and is experiencing weight loss?
Consult with the patient's dietician
Which nursing actions appropriately identify a patient prior to inserting a prescribed nasoenteric tube?
Asking the patient to state his or her name and birth date
Comparing the patient's name and medical record number on the order to the ID band
Which skill should the nurse delegate to a nursing assistive person (NAP) when providing care to a patient who is receiving enteral feedings?
Infusing the patient's feeding per prescriber order
enteral feedings appropriate position is for the patient's head of bed to be at least
30 degrees
Which findings would necessitate further intervention by the nurse when caring for a patient with a gastrostomy tube inserted through the abdominal wall?
Watery stool over the last day
An excessively snug external disk
Redness and irritation at the insertion site
gastrostomy tube inserted through the abdominal wall, watery stool indicates ?
Watery stool often indicates the rate of the feeding is too fast.
The nurse aspirates gastric contents to assess pH in a patient who is prescribed intermittent enteral feedings. In which order
1
first observes the appearance of the
aspirate.
2
mixes the aspirate in the syringe.
3
expel a few
drops of aspirate into a clean medicine cup
4
dips the pH strip into the aspirate fluid
5
Compare the color on the strip to the color chart.
The nurse is preparing the syringe for an intermittent nasoenteric feeding to a patient. In which order
1
pinch the proximal end of the tubing.
2
remove the plunger from the syringe.
3
attach the barrel of the syringe to the end of the
tube
4
fill the syringe with the measured amount of formula and elevate
5
allow the formula to empty gradually by gravity.
The nurse is preparing to administer a nasoenteric feeding to a patient. In which order
1
shaking the formula
2
should cleanse the top of the formula can with alcohol prior to opening
3
fill the container with fluid
4
open the roller clamp on the tubing and
fill to remove air.
5
hang the formula on an intravenous pole.
Which is the priority nursing action when evaluating the patient after the insertion of an enteral feeding tube?
Inspecting the patient's naris for irritation
after examining the patient for naris irritation ?
Assessing the patient's comfort, auscultating the patient's lung sounds, and confirming the patient's x-ray film
Which nursing action is appropriate when providing care to a patient who is prescribed aspiration precautions?
Elevating the head of the bed to a 90-degree angle
( rest period of 30, not 60, minutes prior to meals is appropriate)
The nurse is assessing the patient prior to drawing a prescribed blood glucose level. In which order
1
assess the patient's understanding of the procedure
2
assess the skin at the site to be used for the procedure
3
determine if there are any risk for performing a skin puncture, such as a low platelet count which could increase the patient's risk for bleeding
4
review the health care provider's order for time of frequency of measurement
5
determine if certain conditions must be met prior to
implementing the prescribed procedure.
The nurse is performing blood glucose monitoring for a patient receiving parenteral nutrition. Place the step
1
Assess area of skin to be used as puncture site.
2
Explain procedure and purpose to patient and/or family.
3
Check code on test strip vial
4
Clean puncture site with antiseptic solution.
5
Gently squeeze fingertip until a drop of blood
appears.
6
Wick blood drop into test strip
7
Read results and document in medical record.
how often should blood glucose be measured in pt receiving PN
every 6 hrs
Which nursing action is appropriate when advancing the rate of an intermittent tube feeding?
Infusing a bolus of formula over 20 to 30 minutes
(The rate should be advanced by 60 to 120 mL)
Which medication prescription would the nurse expect to see in the medical record prior to intubating a patient with a nasointestinal (NI) tube?
Metoclopramide,
a prokinetic agent, may be prescribed prior to the intubation of a nasointestinal (NI) tune to help advance the tube into the intestine.
Which nursing action is appropriate when administering an enteral feeding to a patient who is diagnosed with pulmonary aspiration secondary to regurgitation of formula?
Placing the patient in high-Fowler's position
(and for 2 hours after the feeding is complete. )
What should the nurse teach a patient who has altered urinary elimination about maintaining a healthy bladder?
Avoid drinking tea, coffee, or chocolate drinks
A patient should be advised to drink
six to eight glasses of water a day.
even if there is urinary incontinence.
Fluid intake should not be limited
French (Fr) scale size of urinary catheter for a 17-year-old girl.
The nurse should use a 12
statement is true regarding the use of a bladder scanner to measure residual bladder volume?
Women who have had a hysterectomy should be designated as male.
residual bladder volume scan measurement is conducted within
scan measurement is conducted within 10 minutes of voiding.
What nursing intervention is the nurse least likely to provide to a patient diagnosed with stress urinary incontinence related to a weakened pelvic musculature?
Reinforcing teaching related to type 2 diabetes
What nursing intervention is the nurse likely to provide to a patient diagnosed with stress urinary incontinence related to a weakened pelvic musculature?
Encouraging
the patient to lose weight
Advising the patient to maintain adequate hydration
Instructing the patient to avoid caffeine and other bladder irritants
correct amount space allowed between the tip of the penis and the end of the catheter while placing a condom catheter
2.5 to 5 cm
( 1-2 inches )
A nursing instructor asks a nursing student to explain the evaluation phase of a patient who underwent urinary catheterization due to compromised bladder function. Which statement if made by the student indicates a need for further education?
"During the evaluation phase, the nurse explains the procedure and the importance of the catheter to the patient."
evaluation phase of a patient who underwent urinary catheterization due to compromised bladder function.
,the nurse reassesses the patient's urination pattern
urse asks the patient if expectations are being met
nurse asks the patient about any permanent change in elimination
minimum length of an intermittent catheter that should be inserted through the urethral meatus in a female patient?
5 cm
The patient has to provide a urine sample. Which actions should the nurse perform?
Instruct patient to obtain a midstream sample.
Transport specimen to the laboratory within 15-30 minutes.
Refrigerate specimen if it does not reach the laboratory within 30 minutes.
Last-stream samples usually contain
Initial-stream samples contain
dermal contaminants
urethral contaminants
Oliguria
low urinary output in relation to the fluid intake
Polyuria
voiding excessive amounts of urine
Nocturia
awakening from sleep because of the urge to void
Dysuria
pain or discomfort associated with voiding
What is the normal pH range of urine?
4.6 to 8
A nursing instructor asks a nursing student to elaborate on nursing interventions for a patient experiencing stress urinary incontinence related to a weakened pelvic musculature. Which statement if made by the student indicates a need for further learning?
"I should encourage the patient to increase intraabdominal pressure."
catheterizing a patient with a neurogenic bladder. What are the responsibilities of the NAP?
Maintain the privacy of the patient.
Provide perineal care
Assist in the positioning of the patient.
What are the advantages of enteral feeding?
It reduces
sepsis.
(preventing shift of microorgnaisms from lumen to the cells)
It decreases hospital mortality.
It maintains intestinal structure and function.
DECREASES hypermetabolic response of trauma by providing adequate nutrition & calories
Which nursing actions are appropriate when preparing the syringe for an intermittent nasoenteric feeding to a patient?
Pinch the proximal end of the tubing
Remove the plunger from the syringe
Attach the barrel of the syringe to the end of the tube
Fill the syringe with the measured amount of formula and elevate
formula should be administered by gravity and not pushed into the tube forcefully
nursing action promotes safety of a patient who is prescribed continuous enteral feeding?
Correct 1
Using an infusion pump
Using an infusion pump
The nurse aspirates gastric contents to assess pH in a patient who is prescribed intermittent enteral feedings. In which order
1
observes the appearance of the aspirate.
2
mixes the aspirate in the syringe
3
expel a few drops of aspirate into a clean medicine cup.
4
dips the pH strip into the aspirate fluid
5
compares the color on the strip to the color chart
Which priority nursing action complies with the Joint Commission standards and promotes patient safety when administering an enteral feeding by a nasoenteric tube?
Identifying the patient using two identifiers
( It should be done first to limit mistakes of identification. The remaining actions promote safety as well but can be done following identification)
The nurse is providing care to a patient who is prescribed intermittent enteral feedings. Prior to the scheduled feeding, the nurse notes a gastric residual volume (GRV) of 260 mL. Which nursing action is the priority?
Rechecking the GRV in 1 hour
Which nursing action is appropriate when providing care to a patient who is prescribed aspiration precautions?
Elevating the head of the bed to a 90-degree angle
Which nursing action is appropriate when observing a patient for dysphagia during an aspiration risk assessment?
Observing the patient eat various consistencies of food
nursing actions during an aspiration risk assessment
eliciting a gag reflex, measuring the oxygen saturation, and performing a nutritional screening
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