Chapter 13: Promoting Nutrition

Multiple Choice

1. The patient has weakness of the left arm and hand after a stroke. Which is the best nursing intervention to help maintain the patient’s self-esteem during feeding?

a. Delegate feeding to nursing assistive personnel (NAP) to minimize food spillage.

b. Encourage the patient to self-feed as much as possible.

c. Ensure that foods are pureed so they may be consumed through a straw.

d. Collaborate with speech therapist to improve the patient’s nutrition.

ANS: B

The nurse maintains and enhances the patient’s self-esteem by encouraging the patient with positive reinforcement, acknowledging the patient’s progress with self -feeding, and engaging him or her in conversation during feeding. Feeding the patient may reinforce feelings of inadequacy, worthlessness, or embarrassment. Taking food by straw may be contraindicated and increase the risk of aspiration, depending on the patient’s neuromuscular coordination for chewing and swallowing. The speech therapist can contribute to the patient’s nutritional status with specific feeding techniques, but this is not related to self-esteem.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Make a diet request to the health care provider for full liquids. b. Ask the patient’s daughter why the patient will not eat. c. Remind the patient that nutrition is essential to better health. d. Assess the patient for possible reasons for the lack of intake.

2. A patient has not eaten since admission to the long-term care facility 2 days ago. Which is the best initial intervention for the nurse to prevent malnutrition in this patient?

ANS: D

The nurse gathers additional information by using the nursing process to prevent malnutrition for a new patient in the long-term care facility. Identifying barriers to nutrition begins with obtaining objective and subjective data by which the nurse gathers valuable nutritional information, including muscle function, teeth, cognition, and patient food preferences. Requesting a diet change is premature and not based on assessment data. Asking the daughter for information reveals the daughter’s opinion, anecdotal information, and possibly biased observations about the patient. The use of the word “why” is also not therapeutic. Reminding the patient about nutrition may be a useless intervention if his or her cognition is low, if he or she has a sensory or communication disorder, or if he or she is depressed. In addition, the patient can interpret this as an insult to his or her intelligence.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Limit oral intake to clear liquids. b. Allow adequate time for the feeding. c. Ask family members to coach the patient. d. Maintain low-Fowler’s position for meals.

3. A patient with a neurological disease has difficulty swallowing. Which does the nurse include in the plan of care?

ANS: B

The nurse plans an adequate amount of time for patient feeding to address complications from impaired swallowing. With nursing supervision and encouragement and in a relaxed manner, the food is prepared properly; the patient chews food thoroughly, swallows as necessary, and takes short breaks while eating. Clear liquids may be contraindicated for the patient. Thickener may need to be added, depending on the patient’s status. Family coaching may pressure, misdirect, or shame the patient; increase the risk of aspiration or choking; and decrease the patient’s appetite. Low-Fowler’s position is contraindicated for swallowing difficulties and feeding because an upright position facilitates swallowing.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. The patient holds food in the pockets of the mouth. b. The nurse observes no movement of the larynx during swallowing. c. The patient maintains a stabilized weight for 3 consecutive days. d. The patient’s lungs remain clear after eating.

4. The nurse plans care for a patient with impaired swallowing. Which outcome would indicate the priority goal for this patient is being met?

ANS: D

A suitable outcome for a patient with impaired swallowing is that the lungs remain clear after eating, which indicates that the patient did not aspirate. A stable weight over 3 days indicates that the patient is ingesting and absorbing sufficient nutrients to avoid weight loss, which is also indicative of goal outcome. However, an intact airway and lack of aspiration and respiratory complications take priority. Holding amounts of food in the pockets of the mouth indicates difficultly moving the food for chewing and swallowing. Movement of the larynx normally occurs during swallowing.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Suction the airway until clear. b. Turn the patient to a prone position. c. Leave the room to get assistance. d. Instruct the patient to take deep breaths.

5. The patient with impaired swallowing begins to choke while eating. Which action would the nurse implement?

ANS: A

The nurse suctions the oropharynx of a patient with dysphagia who chokes while eating to maintain the airway, the highest priority on the patient’s hierarchy of needs. A positioning change is not indicated unless the patient starts to vomit or becomes unresponsive; then the nurse places the patient in the recovery position. The nurse should not leave the patient until the choking is resolved and the patient is stabilized. The patient should not take deep breaths, which may draw in food and aggravate choking.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Serve the food at room temperature. b. Check for an altered taste perception. c. Encourage the patient to eat with a friend. d. Provide soft, bland foods and snacks.

6. An older patient has been eating approximately 50% of each meal for several days. Which action does the nurse take to increase the patient’s nutritional intake?

ANS: B

The nurse assesses the patient for altered taste perception because the acuity of several senses deteriorates with aging, including the senses of taste and smell; these sensory functions are important for food enjoyment and appetite. To promote health and well-being, the nurse recognizes that the patient is at risk for malnutrition and assesses him or her to gather data for planning care because well-nourished patients are more likely to have positive health outcomes. Serving food at room temperature is an intervention but is not likely to be entirely helpful since it may or may not be the problem. The nurse should find out more information through assessment and then plan appropriately. Eating with a friend can make eating more enjoyable, but, if a physiological reason exists, the reason needs to be addressed first. Serving bland foods is not appropriate at this time. If there is an alteration in ability to taste and smell, bland foods might not be most appetizing to the patient.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Delay self-feeding until the hand tremors subside. b. Show the patient a video of a man feeding himself. c. Provide one piece of adaptive equipment at a time. d. Instruct the patient while assisting him during eating.

7. A patient with a neurological injury resulting in tremors is learning how to feed himself. Which method would the nurse implement to best facilitate learning?

ANS: D

To best facilitate patient learning, the nurse provides verbal instructions while demonstrating feeding techniques to explain each step, provide insight, and clarify directions. This also allows the nurse to assist the patient with eating as needed. Depending on the nature of the injury, the hand tremors can be permanent; so the patient needs to learn self-feeding with hand tremors. Showing a video may be an appropriate intervention, however; this alone is not optimal for teaching and answering questions. All required equipment for self-feeding should be provided to determine which is best for the patient because self-feeding with inadequate equipment can set up the patient for failure. In addition, some pieces of equipment such as a knife and fork are meant to be used simultaneously as needed.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Pork chops b. Noodles c. Rice d. Tea

8. The nurse admits a patient who follows the Jewish faith and maintains a kosher diet. Which food should the nurse withhold to maintain the patient’s dietary practices in accordance with this faith?

ANS: A

The nurse should avoid pork chops. Jewish people who follow the kosher diet are prohibited from eating pork, predatory fowl, shellfish, blood, and meat mixed with dairy products.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Caffeinated tea b. Grilled cheese sandwich c. Milk products d. Lobster chowder

9. The nurse prepares a dietary plan for a patient who practices Orthodox Judaism and notes that no Jewish holidays are approaching. What choices does the nurse plan to exclude from the patient’s menu?

ANS: D

The patient practicing Orthodox Judaism cannot eat shellfish; so the nurse eliminates lobster from the patient’s dietary plan. Orthodox Jewish dietary guidelines do not restrict dietary intake of dairy products except that dairy products are not mixed with meat. The patient’s religious practices allow caffeine in the diet. Caffeine is not prohibited.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Provide oxygen. b. Suction the patient. c. Call for assistance. d. Recline the patient.

10. The nurse assists the patient who had a recent cerebral vascular accident (CVA or stroke) with drinking water, and the patient begins to choke. Which intervention is the best choice to meet the patient’s priority need?

ANS: B

The patient’s priority needs, in order, are airway, breathing, and circulation (ABCs), so the nurse’s priority action is to maintain the airway. To accomplish this, the nurse suctions the patient to prevent an airway obstruction. After the airway is clear, the nurse can provide supplemental oxygen as prescribed if the patient continues to have difficulty or has oxygen desaturation from choking. If the patient continues to have difficulty, the nurse should call for help to obtain emergency equipment. The nurse can place the patient in the recovery position after choking if the patient loses consciousness, continues to choke, or starts to retch or vomit. Reclining the patient is contraindicated because it increases the risk of aspiration.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Long, shiny hair b. Pale conjunctivae c. Pink oral mucosa d. Firm pink nails

11. The nurse receives a report stating that a new patient has a nutritional deficit. Which physical clinical indicator consistent with a nutritional deficit does the nurse expect to observe in the patient?

ANS: B

Pale conjunctivae are a clinical indicator of a nutritional deficit consistent with a low serum hemoglobin or hematocrit. The hematological deficiencies result in a low oxygen-carrying capacity and a deficient number of red blood cells in the blood. This decreases the ability of the erythrocytes to oxygenate the tissues adequately, thereby resulting in pale mucous membranes. Conjunctivae should appear reddish pink. Long, shiny hair and pink oral mucosa are clinical indicators of a patient who consumes an adequate diet. Nails are normally firm and pink.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. The tongue is large with a smooth surface. b. Eighty percent of food was consumed at the last meal. c. Patient reports sense of taste has returned. d. The patient has reddish-pink mucous membranes.

12. The nurse evaluates the plan of care for a patient who is malnourished. Which assessment finding indicates to the nurse that the plan is effective?

ANS: D

Reddish-pink oral and conjunctival mucous membranes are indications of a well-nourished person because this color is consistent with well-oxygenated tissue resulting from adequate amounts of hemoglobin and erythrocytes. A malnourished person is likely to have pale mucous membranes because the individual does not receive adequate nutrition in the diet to provide the body with the necessary iron to synthesize hemoglobin, amino acids to manufacture protein, and other nutrients to manufacture red blood cells in adequate amounts. The tongue is a vivid pink or deep red, with papillae present in adequately nourished individuals. Generally consuming 80% of meals is an acceptable dietary intake; however, a malnourished person usually needs to eat the entire meal on a consistent basis to restore and maintain health and wellness. An intact sense of taste is helpful in maintaining nutrition, but does not indicate if the patient is well-nourished or not.

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DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. White toast with peanut butter b. Pancakes with sliced bananas c. Scrambled eggs with bacon d. Strained soups and custard

13. The health care provider prescribes a mechanical soft diet for the patient. Which food selection would the nurse provide for the patient?

ANS: B

Pancakes with sliced bananas are a suitable food choice for patients on a mechanical soft diet because this diet requires foods that are very easy to chew, require minimal chewing, or allow the patient to eat without teeth. Scrambled eggs are appropriate, but not the bacon. Toast requires chewing, which is unacceptable on the mechanical soft diet. Strained soups and custard are on the full liquid diet.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Orange juice b. Ice cream c. Cranberry juice d. Vegetable juice

14. The health care provider has started the patient on a clear liquid diet. Which item does the nurse provide for the patient?

ANS: C

Cranberry juice is a suitable choice for a patient on a clear liquid diet because this product is made with juice, flavored water, and possibly a sweetener. It is possible to actually see through the liquid. Orange juice, vegetable juice, and ice cream are all dense liquids that the nurse cannot see through. They are suitable for a full liquid diet.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. The patient who refuses most of the meals served. b. The patient who has learned to use adaptive utensils. c. The patient who takes a long time to swallow. d. The patient who is taking ice chips on the first postoperative day.

15. The nurse plans care for four patients and assigns patient feeding to nursing assistive personnel (NAP). Which patient does the nurse watch during mealtime?

ANS: C

Taking a long time may indicate trouble initiating a swallow. This is a symptom of oropharyngeal dysphasia. Until the nurse assesses the patient for dysphagia, consults with other members of the health care team, and collaborates on a plan of care, he or she must assume responsibility for the patient’s aspiration precautions. The nurse instructs the NAP to observe for choking and coughing after mealtime is over. The NAP may be instructed to assist the patient who refuses most meals by encouraging the patient, avoiding coercion to get the patient to eat, and reporting the amount of food eaten by the patient. With training and instruction, the NAP would also be able to assist the patient learning how to use adaptive utensils. The NAP is able to assist the postoperative patient with ice chips.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Hot oatmeal with low-fat milk b. Tomato stuffed with tuna salad c. Lean steak with a baked potato d. Thin spaghetti with tomato sauce

16. After nursing teaching, which food identified by the patient reflects an understanding of the soft diet?

ANS: D

Food on a soft diet must be low in fiber, easily digested, and easy to chew; thus thin spaghetti with tomato sauce is suitable. A soft diet is slightly different from a mechanical soft diet because soft-diet foods must be low in fiber and mechanically soft foods can contain fiber that are pureed or ground. The oatmeal is rich in fiber and is considered a high-fiber food. Fruits and vegetables need to be canned or cooked. The tuna salad has the mayonnaise, which provides quite a bit of fat. The meat must be chewed and is not easily digested.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Review each individual’s height, weight, and health history. b. Teach low-cost menus and methods for a balanced diet. c. Post flyers with instructions for obtaining free vitamins. d. Provide telephone numbers of food banks and free meals.

17. The nurse at a community center is preparing a program for older people at risk for malnutrition who need community resources. Which is the best action for initiating the nurse’s program?

ANS: A

To start a community nutrition program, the nurse applies the nursing process and implements the first step, assessment and data gathering, to determine community needs. The nurse gathers suitable data for planning the program by screening older people for malnutrition and people at risk for malnutrition using a nutritional screening tool. The nurse analyzes the data, including height, weight, and health history to tailor the overall program; organizes suitable resources; plans for individual nutritional assistance; and matches people who are malnourished or at risk with community resources such as food banks, free meals, and Meals on Wheels. The remaining choices do not help the nurse identify people at risk for malnutrition. Teaching about a balanced diet is a prevention technique, and obtaining free vitamins and providing contact information may help people find community resources but doesn’t identify their risk levels.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Immerse the feeding tube in an ice bath. b. Cut a 10.2-cm (4-inch) piece of adhesive tape. c. Inspect the patient’s nares for irritation. d. Remove the guidewire from the feeding tube.

18. The nurse prepares to insert a small-bore intestinal feeding tube. Which instruction does the nurse provide to nursing assistive personnel (NAP) to assist with preparation?

ANS: B

The nurse instructs the NAP to cut a 10.2-cm (4-inch) strip of adhesive tape to secure the feeding tube to the patient’s nose while the nurse supervises the NAP’s action. Icing a feeding tube is never recommended because it would only make the tube stiffer and harder to insert. The nurse is responsible for patient assessment before tube insertion because it requires clinical judgment and critical thinking. The guidewire remains in the feeding tube until placement is confirmed with an x-ray film.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Advance the tube as patient swallows. b. The tube coils in the oropharynx. c. The patient has trouble swallowing. d. Auscultate during air insufflation

19. The nurse prepares to insert a small-bore feeding tube into a patient. Which step of the procedure does the nurse expect during the insertion?

ANS: A

The nurse has the patient swallow water during tube placement to help pull the tube into the correct position. The water also serves as a lubricant. It is expected that the patient will swallow without difficulty to facilitate tube passage through the esophagus and not coil up in the oropharynx. Auscultating for placement would be done after the procedure but is not the recommended procedure to determine placement as it is unreliable.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Attempt to insert the tube into the other naris. b. Advance the stylet and then thread the tube over it. c. Remove the stylet, check it for kinks, and reinsert it. d. Use another stylet to move the tube into position.

20. The nurse cannot advance the small-bore intestinal feeding tube into the patient’s oropharynx. What nursing action will facilitate tube advancement without complications?

ANS: A

The nurse attempts to insert the feeding tube and stylet into the opposite naris after encountering difficulty in the first naris because a physical obstruction is the most likely cause of the problem. The nurse avoids advancing the stylet if the feeding tube does not cover it because the unguarded stylet is likely to cause tissue trauma to the patient’s nasal passageways or oropharynx. Once the stylet is removed from the feeding tube, it cannot be reinserted without damaging the tube. Using a second stylet is contraindicated for tube manipulation.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Gets a pH of 4.0 from the feeding tube aspirate. b. Obtains a pH of 7.0 from the gastric aspirate. c. Listens at the tube distal to the pyloric sphincter. d. Locates the tube above the cardiac sphincter.

21. The nurse inserts a gastric feeding tube into the patient. Which method used by the nurse is most accurate to verify placement of the patient’s feeding tube?

ANS: A

The nurse inserts a gastric feeding tube and expects to confirm tube placement in the stomach; the nurse verifies gastric placement by measuring the pH of the aspirate and expects it to be 5.0 or less because hydrochloric acid from gastric parietal cells acidify gastric contents.

Feeding tube aspirate of 7.0 is most likely from the intestines. A gastric feeding tube is above the pyloric sphincter, the sphincter that controls gastric emptying into the duodenum. The cardiac sphincter is above the area where a pH sample could be obtained.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Document “absent bowel sounds.” b. Gradually decrease the rate of the tube feeding. c. Monitor the patient for possible diarrhea. d. Stop the feeding and notify the health care provider.

22. The nurse assesses the patient who receives continuous enteral nutrition through a nasointestinal tube. What is the priority intervention by the nurse if the patient’s bowel sounds are inaudible?

ANS: D

The nurse stops the tube feeding and collaborates with the health care provider after assessing a patient who receives a continuous tube feeding with no evidence of peristalsis. Without peristalsis, the formula accumulates in the stomach, and eventually the patient can vomit, increasing the risk of aspiration. This finding may also indicate an obstruction or other problem that would contraindicate the feeding. The nurse should document that bowel sounds are absent, but this is not a priority over consulting with the provider. Any patient receiving tube feedings receives nursing assessments for diarrhea and constipation; in addition, if the patient has diarrhea, bowel sounds are likely to be loud, frequent, and high pitched.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Insert a nasogastric tube. b. Withhold the next feeding. c. Notify the patient’s health care provider. d. Administer the next feeding.

23. The nurse is unable to aspirate any residual volume from the patient who receives intestinal tube feedings at a rate of 200 mL every 6 hours by intermittent gavage. Which action by the nurse is most appropriate?

ANS: D

The nurse expects to aspirate no residual volume from the patient who receives intermittent intestinal tube feedings because the small-intestines are unable to sequester fluid. The placement of this type of tube is verified by x-ray film; and, if nothing is aspirated afterward, it is assumed that placement of the tube is correct.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Infuse the formula at room temperature to avoid abdominal cramping. b. Increase the amount of free water with persistent diarrhea or constipation. c. Flush the tube with 500 mL of water after each tube feeding. d. Allow the formula to infuse for 24–48 hours.

24. The nurse prepares the patient for discharge to home with instructions to self-administer nasointestinal tube feedings. Which does the nurse include in patient teaching?

ANS: A

Tube feedings infused into the stomach or intestines bypass food warming that takes place as food passes through the mouth and esophagus; thus the nurse instructs the patient to infuse the formula at room temperature to avoid abdominal cramping. The patient should report diarrhea or constipation to the health care provider before implementing additional fluids since these may be indications of other complications of tube feedings. Flushing with 500 mL of water after each tube feeding is excessive and risks causing fluid volume overload in the patient and can raise the risk of vomiting and aspiration. Because nasointestinal feedings generally infuse continuously, the nurse instructs the patient to replace the feeding bag and tubing every 24 hours and flush the tubing before and after each new infusion. The nurse instructs the patient to infuse the same can of formula for up to 8 hours without adding formula over the infusion period.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Administer medication with a 10-mL syringe. b. Change the feeding tube bag every 8 hours. c. Add enough formula to the bag to last 24 hours. d. Check the placement of the tube with a 60-mL syringe.

25. The patient is receiving nasointestinal tube feedings by continuous drip from an open system. Which procedure should the nurse use when caring for this patient?

ANS: D

The nurse checks tube placement and administers medication with a 60-mL syringe. The feeding tube bag is changed every 24 hours to prevent bacteria buildup in the system. The maximum time that formula can hang in an open system is 8 hours. The 10-mL syringe would cause excessive positive pressure into the feeding tube. Placement is checked using a 60-mL syringe.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. The aspirated liquid totals 5 mL of greenish fluid. b. The feeding tube collapses with negative pressure. c. The nurse aspirates a small amount of the formula. d. The aspirated liquid appears pale and straw colored.

26. The nurse aspirates fluid from the nasointestinal tube. Which finding requires the nurse to plan follow-up nursing interventions?

ANS: D

The nurse plans follow-up nursing interventions after aspirating pale and straw-colored fluid because intestinal aspirate should be green, indicative of the bile concentration of the fluid. Because the aspirate is inconsistent with clinical indicators for intestinal fluid, the nurse investigates further to verify tube placement before instilling anything into the nasointestinal tube. The nurse expects to aspirate a small amount of greenish fluid indicative of bile in the fluid. This also indicates placement of the nasointestinal tube in the intestines because the intestines cannot hold large amounts of fluid as the stomach can. The nasointestinal tube is expected to collapse with negative pressure because it is a soft pliable tube. A small amount of formula aspirated is not a problem and does not require follow-up. It is acceptable.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Withhold tube feedings if unable to obtain aspirate. b. Check tube placement by instilling air into the tube. c. Administer the tube feedings at 7.22° C to 10° C (45° F to 50° F). d. Report aspirate with a pH less than 6.0 to the provider.

27. The nurse instructs the patient to self-administer nasointestinal tube feedings at home. Which is the best instruction to include in patient teaching about aspirating the tube?

ANS: D

The nurse instructs the patient to report a pH less than 6.0 of the intestinal aspirate because this fluid should be alkaline and have a pH greater than 6.0 from exposure to intestinal fluid and bile. If a patient who is able to competently handle administering a nasointestinal feeding at home aspirates and obtains no fluid, the nurse assumes that the infusion is operating without difficulty because no aspirate is an expected finding. The nurse avoids instructing the patient to instill air to verify tube placement; however, he or she instructs the patient to instill 30 mL of air before aspirating gastric fluid to displace the fluid and facilitate aspiration. Tube feeding formula should be at room temperature to avoid abdominal cramping.

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DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Respirations are 28–32 breaths/min. b. The residual volume is less than 100 mL. c. A stable weight over 1 month. d. Urine output has increased from 25 to 30 mL/hr.

28. The nurse is planning care for the patient receiving nasogastric tube feedings. What reassessment information would best indicate to the nurse that a successful therapeutic regimen has been established?

ANS: B

A clinical indicator of a successful therapeutic regimen in this patient is a residual volume below 100 mL. This indicates the stomach is emptying gastric contents into the duodenum and precipitating intestinal peristalsis. The peristaltic action moves the formula through the gastrointestinal tract to prevent formula accumulation in the stomach. Tachypnea in a patient with gastric tube feedings warrants further investigation by the nurse because tachypnea is consistent with clinical indicators for aspiration. A stable weight over one month is consistent with delivering inadequate calories. The patient should be gaining weight. The nurse expects urine output between 30 and 50 mL/hr, depending on the patient; however, this is not related to a successful feeding regime.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Up to 8 hours b. Up to 24 hours c. 10–15 minutes d. 30–45 minutes

29. The nurse is caring for a patient on intermittent gavage tube feedings. Over what period of time should the nurse infuse each feeding?

ANS: D

The nurse allows the intermittent tube feeding to infuse over 30–45 minutes by gravity to reduce the risk of abdominal discomfort, vomiting, or diarrhea induced by bolus or excessively rapid formula infusions. Infusions of 8 or 24 hours defeat the purpose of an intermittent infusion because the therapy is mimicking normal eating patterns. Infusions of 10

15 minutes are too rapid and increase the risk of aspiration.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Return the aspirate and continue with the feeding. b. Flush the tube with 30 mL of normal saline solution. c. Return the aspirate and reevaluate patient in 1 hour. d. Collaborate about the aspirate with the provider.

30. After 2 days of administering the patient’s continuous nasogastric tube (NGT) feeding at 35 mL/hr successfully, the nurse aspirates 150 mL of formula. Which should the nurse implement first?

ANS: A

Best evidence suggests that a single high gastric volume residual GRV should be monitored for the following hour, but enteral feeding should not be stopped or withheld for an isolated high GRV, so the nurse returns the 150-mL aspirate, documents the event, and communicates the finding to the next nurse. If on several occasions the nurse aspirates more than 150 mL, the nurse notifies the provider. Excessive NGT aspirate warrants further investigation by the nurse at that time and requires the nurse to assess the patient carefully on restarting the feeding. The nurse flushes the NGT after discarding the excessive NGT aspirate to maintain tube patency. The nurse returns the aspirate if the volume is less than 200 mL. There is no reason to contact the provider at this point.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. 30 mL b. 60 mL c. 120 mL d. 150 mL

31. The patient receives three different medications through a nasogastric tube (NGT). Which total fluid volume does the nurse anticipate instilling to administer these medications properly?

ANS: C

The nurse expects to instill at least 120 mL of fluid to administer three medications by NGT because he or she flushes the tube with 30 mL of water before and after each medication, resulting in four flushes or 120 mL.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. An intact gag reflex b. An occluded right naris c. Impaired swallowing d. Absent bowel sounds

32. The nurse prepares to insert a patient’s nasogastric tube (NGT) for tube feedings. Which patient assessment requires the nurse to collaborate with the patient’s health care provider before initiating the feeding?

ANS: D

The nurse collaborates with the provider before initiating tube feedings for a patient without bowel sounds because any formula infused is likely to accumulate in the stomach and greatly increase the patient’s risk of aspiration. Even so, peristalsis is normally stimulated as food accumulates in the stomach, activates stretch receptors, and stimulates peristalsis in the smalland large intestines. Indications for NGT feedings exist for patients with and without a gag reflex. The nurse attempts NGT insertion into the left nostril when the right nostril is occluded. Patients with impaired swallowing are suitable candidates for NGT feedings.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Advances the nasogastric tube while the patient swallows. b. Instructs the patient about self-care of the feeding tube. c. Eases insertion by icing down the nasogastric tube. d. Measures the length from the patient’s nose to the sternum.

33. The patient receives a prescription for tube feedings. Which does the nurse implement while inserting a nasogastric tube for this patient?

ANS: A

The nurse instructs the patient to swallow while the tube advances because the coordinated muscular action of the esophagus helps to direct it down through the cardiac sphincter and into the stomach. The nurse can provide patient teaching after the tube insertion because instruction provided before the insertion is unlikely to be retained. Briefly immersing the end of the tube in warm water eases insertion by softening the end of the tube for passage through the nasal passageway. The nurse measures the length of the nasogastric tube properly by measuring from the tip of the nose to the earlobe to the xiphoid process.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Measures from the nose to the earlobe to the xiphoid process. b. Removes the guidewire after verifying placement. c. Places the patient on the left side until verifying placement. d. Anchors the tube with tape after insertion.

34. The nurse prepares to insert a nasointestinal tube into a patient. Which does the nurse implement for proper tube placement?

ANS: B

The nurse maintains the guidewire in place until intestinal placement is verified because, once it is removed, it cannot be reinserted. If the tube needs repositioning, the nurse cannot manipulate it effectively. The nurse measures from the tip of the nose to the earlobe to the xiphoid process and adds 20–30 cm for a proper length. Positioning the patient on the left or right side does not facilitate migration of the tube into the intestines. The nurse anchors the nasointestinal tube in place after placement in the jejunum is verified.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Septicemia b. Pancreatitis c. Gastric ileus d. Head trauma

35. The nurse is determining whether an order for a nasogastric tube feeding is appropriate. Which patient diagnosis would prevent the nurse from initiating a tube feeding?

ANS: C

Gastric ileus, or gastroparesis, is a contraindication to nasogastric tube feedings because infused formula into the stomach is likely to remain in the stomach and accumulate. This increases the risk of aspiration and endangers the patient’s airway. The duty the nurse owes the patient is to withhold a tube feeding until bowel sounds are present. Pancreatitis, sepsis, and head trauma are indications for tube feedings as long as the patient has peristaltic action.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Instill the formula immediately after removing it from refrigeration. b. Infuse the formula over 10–15 minutes. c. Raise the syringe 18 inches above the insertion site. d. Attach the feeding bag to the proximal end of the NIT.

36. Before administering a continuous nasointestinal tube (NIT) feeding, the nurse verifies placement of the patient’s NIT and flushes it with water. Which step does the nurse perform next?

ANS: D

For a continuous tube feeding, the nurse attaches the feeding bag tubing to the proximal end of the NIT to begin the infusion and connects the tubing through the infusion pump. Cold formula can cause cramping. Formula should be administered at room temperature. A continuous infusion infuses around-the-clock; if the feeding is an intermittent infusion, the nurse administers it over 30–60 minutes. The nurse administers a continuous infusion with a feeding bag; intermittent infusions can be administered with a syringe.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

Multiple Response

1. The nurse instructs the caregiver to administer the patient’s intermittent tube feeding. Which does the nurse include in caregiver teaching? (Select all that apply.)

a. Maintain tube patency with frequent irrigations.

b. Keep the feeding tube capped between feedings.

c. Complete feeding before checking tube placement.

d. Weigh the patient twice a day for the first month.

e. Store opened cans of formula in the refrigerator.

ANS: B, D

The nurse instructs the caregiver to cap the feeding tube for an airtight seal between feedings to prevent the contents of the tube from drying and occluding the tube. Flushing a feeding tube too frequently is associated with tube occlusion. The nurse confirms tube placement before infusing the formula. The nurse instructs the caregiver to refrigerate opened cans of formula. Bacteria grows at room temperature once the cans are opened, spoiling the formula. The patient receiving home enteral nutrition should be weighed daily or weekly, depending on the patient’s condition.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Integrated Process: Teaching-Learning a. Cleanse the site with Betadine. b. Place the dressing under the external bar. c. Assess the site for evidence of drainage or infection. d. Apply a thin layer of skin barrier to exit site. e. Use sterile gloves for the procedure.

2. The nurse instructs the new orientee to care for the gastrostomy site. Which items does the nurse include in her teaching? (Select all that apply.)

ANS: C, D

The site should be cleansed with soap and water and assessed for excoriation, drainage, infection, or bleeding. The nurse should apply a barrier protective cream if ordered. The dressing goes over the external bar. Placing it under the bar can cause tissue erosion. Sterile gloves are not required; clean gloves are used.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation