Nutrition

Question 1

how often do you clean a reusable feeding system and with waht

Answer 1

every 24 hours with warm soap and water

Question 2

how long do you keep pt at 30 degrees while enteral feeding?

Answer 2

during the feeding and 1 hour after

Question 3

when do you flush a feeding tube?

Answer 3

every four hours for continuous feeding and after aspirating for gastric contents

Question 4

how do you fix an enteral feeding tube occulustion

Answer 4

use a 60mL syringe contains 30-60 mL of warm water

Question 5

comfort measures for enteral feeding tube

Answer 5

oral hygiene 2-4 hours
lubricate lips
local irritation with analgesic throat logenzes
have pt verbalize concerns

Question 6

Hold feeding if

Answer 6

residual contents in 200mL on 2 successive assessments

Question 7

that which structure in the gastrointestinal system absorbs the majority of digested food and mineral

Answer 7

small intestine

Question 8

Which laboratory value would be indicative of a client’s level of malnutrition?

Answer 8

serum albumin

Question 9

some nursing actions that prevent complications during enteral feeding

Answer 9

• Clean and moisten the nares every 4 to 8 hours.
• Flush the tube before and after feeding.
• Elevate the head of the bed at least 30 degrees during the feeding and for at least 1 hour afterward.

Question 10

when a nurse meets resistance while irrigating a ng tube the nurse should assess the patient for

Answer 10

n/v, gastric fullness, stomach distention

Question 11

what is the most serious complication of NG tube feeding?

Answer 11

Aspirating stomach contents

Question 12

for contineous feeding how often should the nurse confirm placement of the tube

Answer 12

every 4-6 hours

Question 13

angle of bed when inserting NG tube

Answer 13

high fowlers or at least 45*

Question 14

what pH would indicate the nurse that fluid is gastric

Answer 14

less than 5.5

Question 15

Steps for removing NG tube

Answer 15

1) remove tape
2) separate NG tube from suction
3) aspirate gastric content with syringe to check fro placement of tube
4) flush NG tube with 10mL of NS (or 30-50mL of air)
5) clamp ng tube with fingers
6) ask pt to take deep breath
7) pull out
8) make sure to measure ng drainage
9) offer oral hygien

Question 16

which nostril do you put ng tube into

Answer 16

the one its easier to breath out of

Question 17

steps for inserting NG tube

Answer 17

1) check which nostril to use
2) measure to from nose to ear and ear to xyphoid process
3) mark measurement with tape
4) lubricate the tip
5) ask pt to lift head
6) if pt hesitates ask them to put chin to chest and drink water
7) advance tube when pt breaths
8) check to make sure in stomach by aspirating a small amount of stomach content
9) tape nose
10) measure and record tube length (tip of nose to end of tube)
11) air vent should be above level of stomach
12) attach pt to suction
13) offer oral hygiene

Question 18

what color should stomach content be

Answer 18

green with particles
brown if old blood is present
clear to straw color

Question 19

how to check if NG is placed in stomach

Answer 19

check color
measure pH (less than 5.5)
x-ray

Question 20

during continous tube feeding what angle should the hob be at during feeding?

Answer 20

30-45*

Question 21

when irrigating an NG, the nurse does not get a return after instilling solution and reconnection the tube back to the suction. What should the nurses next step in this situation?

Answer 21

Instill 20mL of air into the tube and aspirate again

Question 22

irrigating an NG tube

Answer 22

1) check placement of NG tube by aspirating
2) disconnect NG tube from suction
3) place tip of syringe in NG tube
4) aspirate
5) draw up irrigation amount
6) place syringe in NG tube
7) slowly insert solution
8) clamp tube
9) connect NG tube back to suction
10) unclamp to withdraw fluid

Question 23

How should you pull out an NG tube and what do you ask the pt to do?

Answer 23

ask the pt take a deep breath and pull out the tube quickly and carefully

Question 24

The nurse is removing an NG tube from a pt, flushes the NG tube prior to removing it. What should the nurse do next

Answer 24

Instill 30-50 mL of air to clear the tube

Question 25

If a pt has stable eschar on the heel. What nursing intervention would you perform

Answer 25

none, stable eschar (dry adherent, intact, without erthema or fluctuance) on the heel serves as body natural cover and should not be removed.

Question 26

The nurse has finished cleaning a pts surgical wound has applied a dry, sterile dressing. How often would the nurse check the wound dressing

Answer 26

every shift

The nurse checks all wound dressings every shift, may be needed more if the wound is more complex

Question 27

A nurse is removing the dressing from an abd surgical wound site and notes that edges are not intact and multiple staples on the dressing and the surrounding tissue is red with purulent drainage, the chart reports the incision was clean and dry with approximated edges and staples intact upon the last assessment. What would be the first recommended nursing intervention in this situation?

Answer 27

Assess for pain, SOB, and abd pressure

When excessive drianage appears on the dressing first assess pts sob, pain and abd pressure.
Then place pt in supine to reduce pressure.
Then place a dry sterile dressing on the wound site and assess vital and assure pt and contact pcp.

Question 28

The order in which the nurse would preform the steps for Jackson-Pratt drain

Answer 28

1) empty the chambers contents completely into the container
2) use gauze pad to clean outlet
3) fully compress the chamber
4) replace the cap
Clean gloves would be put on prior to emptying the chamber

Question 29

The nurse is attempting to insert an NG tube and, as the tube is passing through the pharynx, the client begins to retch and gag. What nursing interventions are appropriate in this situation? Select all that apply

Answer 29

• Ask the client if he needs to pause before continuing insertion.
• Continue to advance tube when the client relates that he is ready.
• Have the emesis basin nearby in case client begins to vomit.

Question 30

pts with increase nutritional requirements and those who will be NPO for more than ___ may require nutrient from enteral nutrition

Answer 30

2 days

Question 31

What is considered short term nutritional support.

Answer 31

4 weeks

Question 32

before each feeding check

Answer 32

tube length and compare with inital measuremtns in conjunction wiTh pH measurement and visual assessment aspiration

Question 33

what should stomach ph be

Answer 33

5.5 or less

Question 34

what should intestinal ph be

Answer 34

7.0 or higher

Question 35

what should respiratory tract ph be

Answer 35

6.0 or higher

Question 36

the preferred route to deliver enteral nutrition to a comatose pts is the

Answer 36

PEG

Question 37

what is the preferred method of gastric feeding

Answer 37

intermitted

Question 38

TPN therapy complication

Answer 38

complications r/t the use of CVAD such as pneumothorax and thromboembolism, infection, sepsis, metAbolic alteration, fluid and elctrolyte and acid base alteration, phlebitis, hyperlipidema, liver and gall bladder disease