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Terms in this set (37)Which pieces of equipment should the nurse have available to intubate a patient with a feeding tube? Select all that apply. Towel Towel In which position should the nurse place the patient to conduct blood glucose monitoring? Prone Semi-fowlers Which complication may occur if the nurse were to add food coloring to the formula for a patient who is prescribed enteral feeding? Aspiration Hypotension Which nursing action is appropriate when providing care to a patient who is prescribed aspiration precautions and is experiencing weight loss? Cluster care for the patient Consult with the patients dietician Which are possible causes for constipation in a patient who is prescribed enteral tube feedings? Select all that apply. Inactivite Inactivity How can the nurse determine the length of the tube needed for a nasointestinal (NI) intubation? Subtracting 10 to 20 cm (4 to 8 in) to the
measured length of the tube Adding an additional 20 to 30 cm (8 to 12 in) to the measured length of the tube Which assessments should the nurse perform prior to inserting a nasoenteric tube for enteral feedings? Select all that apply. Height Height Which nursing action is appropriate when planning to intubate a patient with a prescribed feeding tube? Auscultating bowel sounds Explaining the sensations that are expected Which nursing action supports safety guidelines that are essential when providing care to a patient who is receiving a tube feeding? Using surgical aseptic technique Allowing the open formula system to hang for no more than 8 hours Which skill should the nurse delegate to nursing assistive personnel when providing care to a patient receiving enteral feedings? Inserting the patient's tube Positioning the patient during insertion Which data should nurse document in the patient's medical record after the intubation of an enteral tube? Select all that apply. Type of tube Type of tube 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 Rechecking the GRV in 1 hour Which statement by the nurse exemplifies the Teach Back method to determine patient and family understanding regarding dysphagia? "How do you currently prevent choking?" I want to be sure I properly explained dysphagia and how to prevent choking. Can you explain to me why these steps protect you from choking Which nursing action is appropriate when providing care to a patient who is prescribed aspiration precautions? Eliciting a gag reflex Elevating the head of the bed to a 90-degree angle Which is the priority nursing action when intubating a patient with a feeding tube? Donning sterile gloves Verifying the health care provider's order Which nursing action is appropriate when providing care to a patient who develops diarrhea three times or more in 24 hours as a result of enteral feedings? Holding the patient's current feeding Instituting skin care measures for the patient Which is the first nursing action when monitoring a patient's blood glucose level? Performing hand hygiene Performing hand hygiene The nurse aspirates gastric contents to assess pH in a patient who is prescribed intermittent enteral feedings. In which order should the nurse perform the following actions? Mix the aspirate in the syringe. Observe the appearance of the aspirate Which nursing action is appropriate prior to administering a nasoenteric feeding? Monitoring the platelet count Assessing capillary blood glucose Which nursing action is appropriate when providing care to a patient who experiences pulmonary aspiration due to enteral feedings? Suctioning the airway Suctioning the airway Until radiographic confirmation of placement of an intestinal tube is completed, in which position should the nurse place the patient after intubation? Prone Side-lying Which nursing action is appropriate when advancing the rate of an intermittent tube feeding? Infusing a bolus of formula over 20 to 30 minutes Infusing a bolus of formula over 20 to 30 minutes Which are the rights the nurse should implement to enhance safety for a patient who is prescribed enteral feedings? Select all that apply. Dose Tube The nurse is preparing the syringe for an intermittent nasoenteric feeding to a patient. In which order should the nurse perform the following actions? Remove the plunger from the syringe Pinch
the proximal end of the tubing The nurse is intubating a patient with a feeding tube. In which order should the nurse perform the following actions? Anchor the tube to the patient's nose. Perform hand hygiene, and apply clean gloves. The nurse is assessing the patient prior to drawing a prescribed blood glucose level. In which order should the nurse perform the following actions? Determine if there are any risks for performing a skin
puncture Assess the patient's understanding of the procedure The nurse is feeding a patient with dysphagia. Which position of the patient should be avoided to reduce the risk of aspiration? Supine Supine The nurse is preparing to administer a nasoenteric feeding to a patient. In which order should the nurse perform the following actions? Fill the container with formula Shake
the formula Which nursing action is appropriate when removing an enteral feeding tube from the patient? Placing the patient in low-Fowler position Pulling the patient's tube steadily and smoothly Which nursing actions are appropriate when obtaining gastrointestinal (GI) aspirate for pH measurement in a patient who is prescribed continuous tube feedings? Select all that apply. Drawing 30 mL of air into the syringe Drawing 30 mL of air into the syringe How often should the nurse check gastric residuals for patients who are prescribed aspiration precautions? Every 2 hours Every 4 hours The nurse is caring for a patient who is on enteral feeding. What are the advantages of enteral feeding? Select all that apply. It reduces sepsis. It reduces sepsis. Which findings would necessitate further intervention by the nurse when caring for a patient with a gastrostomy tube inserted through the abdominal wall? Select all that apply. Watery stool over the last day Watery stool over the last day Which nursing action is appropriate for a patient with a gastric aspirate of 150 mL? Return all the aspirate Return all the aspirate Which priority nursing action complies with the Joint Commission standards and promotes patient safety when administering an enteral feeding by a nasoenteric tube? Explaining the procedure to the patient Identifying the patient using two identifiers The nurse is performing blood glucose monitoring for a patient receiving parenteral nutrition. Place the steps of the procedure in the correct sequence. Explain procedure and purpose to patient and/or family. Assess area of skin to be used as puncture site. Which nursing action promotes safety of a patient who is prescribed continuous enteral feeding? Using an infusion pump Using an infusion pump Sets with similar termsEnteral Nutrition NCLEX Practice QUIZ57 terms jeanelle_baldric Module 539 terms thepinkspoon VN 136 CH. 19 & 27 FINAL68 terms sondra_mccart NUR 3028 -NG tube, Enteral Nutrition sample questi…15 terms RNRice Sets found in the same folderChapter 45 Nutrition31 terms allybailey217 3101 Skills: chap. 45 Nutrition48 terms SaySay98 Chapter 45 Fundamentals35 terms brooke_fries Adaptive Quizzing Chapter 45 Nutrition43 terms timbrook7609 Other sets by this creatorNCLEX prep acid base balance6 terms timbrook7609 NCLEX prep lab values41 terms timbrook7609 HESI MEDS299 terms timbrook7609 Developmental Milestones46 terms timbrook7609 Other Quizlet setsPsychology 012 - Psychological Methods: Research P…42 terms kahemamrahs Financial Accounting - Chapter 1048 terms Joyce267 Physiology Final Exam Review47 terms Ashley_Heyen Commercial Property Policies66 terms Sabria_Simon Related questionsQUESTION What is the teres minor? What nerves? 15 answers QUESTION A patient is diagnosed with hypophosphatemia caused by an increased excretion of phosphate. Which probable cause for this condition should the nurse include in the teaching session with the patient? 13 answers QUESTION When providing care to a patient with increased intracranial pressure, the nurse would be concerned about which clinical finding because it can result in an additional increase in intracranial pressure? 3 answers QUESTION Tidaling in water chamber of chest tube is.... 15 answers How does the nurse determine the length of the tube needed for a Nasointestinal intubation?To determine the length of the tube needed for a nasointestinal (NI) intubation, the nurse should add an additional 20 to 30 cm (8 to 12 in) to the measured length of the tube. Subtracting anything from the measured length and adding an 10 to 20 cm (4 to 8 in) will result in an inaccurate length.
How would the nurse determine the length of tube needed to reach the stomach for nasogastric feeding?To minimize the possibility of aspirated gastric content from coming in contact with the patient, place a towel or protective pad over the chest of the patient. Using the NG tube, measure the length from the earlobe to xiphoid process and from the nose to the earlobe to determine the length that the NG tube must be.
Which assessment would the nurse perform prior to inserting a nasogastric tube for enteral feedings?For administering enteral feedings via nasoenteric tube, the nurse should first place the patient in high-Fowler's position or elevate the head of the bed at least 30 degrees. The nurse should then verify the tube placement by attaching the syringe and aspirating 5 mL of gastric contents.
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How does the nurse determine the length of the tube needed for a nasal intestinal intubation
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