Show
Home Subjects Expert solutions Create Log in Sign up Upgrade to remove ads Only ₩37,125/year
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, nursing action is inappropriate when checking for gastric residual volume (GRV) before each enteral feeding? Discarding gastric contents 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, 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 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, 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 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 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, equipment should the nurse have available when testing a patient's blood glucose level? lancet, 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 may cause diarrhea, in a patient who is prescribed enteral tube feedings? Malabsorption, 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 ) 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 Which nursing actions are appropriate when checking for gastric residual volume (GRV) before each enteral feeding? Flushing
the tube with 30 mL of water 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 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 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 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 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 The nurse is preparing the syringe for an intermittent nasoenteric feeding to a patient. In which order 1 The nurse is preparing to administer a nasoenteric feeding to a patient. In which order 1 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 The nurse is performing blood glucose monitoring for a patient receiving parenteral nutrition. Place the step 1 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 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 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 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. Last-stream samples usually contain dermal 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. What are the advantages of enteral feeding? It reduces
sepsis. 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? 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 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 Sets found in the same folderChapter 45 Nutrition31 terms allybailey217 Chapter 39 (Nursing Skills Activity and Exercise)30 terms MWright777 Tissue Integrity Test 6182 terms MWright777 Evolve adapting quizzing chapter 4020 terms isabelk490 Other sets by this creatort14 Leadership & Mgmt34 terms wangotango t13. Leadership & Mgmt83 terms wangotango t12. Gi & Nutrition144 terms wangotango t11. Leadership & Mgmt113 terms wangotango Other Quizlet setsChapter 20: Care of Patients with Hypersensitivity…13 terms litteraln NUR 184 U3118 terms Bri10ives COI FINAL49 terms Julia_Breighann Chapter 20: Care of Patients with Hypersensitivity…12 terms tati_0901PLUS Related questionsQUESTION - What does CSF look like in meningitis? 14 answers QUESTION What are the functions of the head? 15 answers QUESTION A nurse is providing a client with preoperative education. The nurse knows that which teaching point should be included in the instruction regarding deep breathing and coughing exercises? 3 answers QUESTION what do you do for neurogenic shock? 10 answers Which nursing action is appropriate when providing care to a patient who is prescribed intermittent tube feedings quizlet?The appropriate nursing action when providing care to a patient who is prescribed intermittent tube feedings is to check tube placement prior to each feeding.
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.
Which nursing action prevents gastric cramping and discomfort during a Nasoenteric?Which nursing action prevents gastric cramping and discomfort during a nasoenteric feeding? feeding a patient with dysphagia. Which position of the patient should be avoided to reduce the risk of aspiration?
Which nursing action is priority when intubating a patient with a feeding tube?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.
|
Which nursing action appropriately identifies a patient prior to inserting a prescribed Nasoenteric tube?
zusammenhängende Posts
Urheberrechte © © 2024 ketiadaan Inc.
