Chapter 31: Enteral Nutrition Nursing School Test Banks

MULTIPLE CHOICE

1. Of the patients listed below, which would be a candidate for nasoenteric feeding tube placement?

a.

Postmotor vehicle accident victim with a broken nose and jaw

b.

Patient with a bleeding ulcer and possible esophageal varices

c.

Elderly patient with a diagnosis of failure to thrive and an inability to chew

d.

Patient with an esophageal tumor

ANS: C

Enteral nutrition, commonly called tube feeding, is the administration of nutrients through the gastrointestinal tract when a patient cannot ingest, chew, or swallow, but can digest and absorb nutrients. Nasoenteric tubes are contraindicated in patients with facial trauma, prolonged bleeding, and upper gastrointestinal (GI) blockage (as is seen in cases of solid cancer).

DIF: Cognitive Level: Analysis REF: Text reference: p. 775

OBJ: Assess the patient who is to receive enteral tube feedings.

TOP: Indications/Contraindications for Nasoenteric Tube Insertion

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

2. The nurse has just inserted a nasogastric (NG) feeding tube into a patient. What should the nurse do to definitely ascertain that the tube is in the stomach or in the intestine?

a.

Test the pH of the contents.

b.

Use a carbon dioxide sensor.

c.

Lower the head of the bed to 15 degrees.

d.

Obtain an order for a chest radiograph.

ANS: D

The most reliable method of feeding tube verification is a chest radiograph (chest x-ray). Gastric and intestinal pH measurements have been shown to differentiate tube placement, with the stomach having a lower pH than the intestines. This helps to ensure that the tube is beyond the pylorus, theoretically reducing the risk for aspiration. This method is helpful before and after radiological confirmation. Carbon dioxide sensors are helpful in determining tube placement between the stomach and the lung. A small plastic piece with an embedded yellow sensor is attached to the end of the feeding tube; the sensor changes color when carbon dioxide is present. Investigators have shown that this reduces the incidence of inadvertent pulmonary placement. This method is helpful before and after radiological confirmation. Elevation of the head of the bed to a minimum of 30 degrees is a simple method used to keep the risk for aspiration at a minimum. The nurse is instrumental in achieving this goal. This method does not ascertain placement but may be useful in preventing aspiration.

DIF: Cognitive Level: Application REF: Text reference: p. 776 |Text reference: p. 781

OBJ: Demonstrate ability to correctly insert a small-bore feeding tube.

TOP: Determining Position of NG Tubes

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. The nurse is checking gastric residual on a patient who has a continuously running tube feeding. She finds that the patient has a 600-mL residual volume. How should the nurse respond?

a.

Stop the tube feeding.

b.

Slow the tube feeding.

c.

Continue the tube feeding at the same rate.

d.

Increase the rate of the tube feeding.

ANS: A

Tube feedings are stopped if the patient has high gastric residual (more than 500 mL).

DIF: Cognitive Level: Application REF: Text reference: p. 776 |Text reference: p. 790

OBJ: Assess the patient who is to receive enteral tube feedings.

TOP: Residual Volume KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. Before insertion of a nasogastric (NG) tube, of which finding should the physician be notified?

a.

Patent nares

b.

Absent bowel sounds

c.

Evident gag reflex

d.

Impaired swallowing

ANS: B

Absent bowel sounds may indicate decreased or absent peristalsis and increased risk for aspiration. A finding of patent nares rules out obstruction or irritated nares, septal defect, or facial fracture and does not need to be reported to the physician because it is a normal finding. The nurse should assess the patient for a gag reflex to determine the patients ability to swallow and to discern whether a greater risk for aspiration exists. An evident gag reflex is a normal finding and does not need to be reported to the physician. Impaired swallowing is the probable reason for insertion of the NG tube.

DIF: Cognitive Level: Application REF: Text reference: p. 777 |Text reference: p. 789

OBJ: Demonstrate ability to correctly insert a small-bore feeding tube.

TOP: Absent Bowel Sounds KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

5. An appropriate technique for nasogastric (NG) tube insertion is for the nurse to:

a.

position the patient supine.

b.

apply oil-based lubricant to the plastic tube.

c.

advance the tube while the patient swallows.

d.

measure the tube length from the nose to the sternum.

ANS: C

Encourage the patient to swallow by giving small sips of water or ice chips. Advance the tube as the patient swallows. Rotate the tube 180 degrees while inserting. Swallowing facilitates passage of the tube past the oropharynx. Position the patient sitting with the head of the bed elevated at least 30 degrees. If the patient is comatose, place him in semi-Fowlers position with the head propped forward using a pillow. If the patient is forced to lie supine, place him in reverse Trendelenburgs position. This reduces the risk for pulmonary aspiration in the event that the patient should vomit. Apply water-soluble lubricant. The tip of the tube must reach the stomach. Measure the distance from the tip of the nose to the earlobe to the xiphoid process of the sternum. Add 20 to 30 cm (8 to 12 inches) for a nasoenteric tube.

DIF: Cognitive Level: Application REF: Text reference: p. 779

OBJ: Demonstrate ability to correctly insert a small-bore feeding tube.

TOP: NG Tube Insertion KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

6. Which technique is appropriate for the nurse to implement during nasogastric (NG) tube insertion?

a.

Use sterile gloves.

b.

Have the patient mouth-breathe.

c.

Advance the tube quickly when the patient coughs.

d.

Bend the patients head backward after the tube is through the nasopharynx.

ANS: B

Emphasize the need to mouth-breathe and swallow during the procedure. This facilitates passage of the tube and alleviates the patients fears during the procedure. Put on clean gloves. Do not force the tube. If resistance is met, or if the patient starts to cough or choke, or becomes cyanotic, stop advancing the tube, pull the tube back, and start over. Have the patient flex his head toward his chest after the tube has passed through the nasopharynx. This closes off the glottis and reduces the risk that the tube may enter the trachea.

DIF: Cognitive Level: Application REF: Text reference: p. 779

OBJ: Demonstrate ability to correctly insert a small-bore feeding tube.

TOP: NG Tube Insertion KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7. The nurse has inserted a nasogastric (NG) feeding tube. The feeding tube has a stylet in place to aid insertion. What should the nurse do once the tube is in place?

a.

Remove the stylet immediately.

b.

Reinsert the stylet if the radiograph determines incorrect placement.

c.

Fasten the end of the NG tube to the patients gown using tape and a safety pin.

d.

Leave the stylet in place and obtain a chest/abdomen radiograph.

ANS: D

Leave the stylet in place (if used) until correct position has been verified by x-ray film. Never attempt to reinsert a partially or fully removed stylet while the feeding tube is in place. This can cause perforation of the tube and can injure the patient. Do not use safety pins to pin the tube to the patients gown. Safety pins become unfastened and can cause injury to the patient.

DIF: Cognitive Level: Application REF: Text reference: p. 781

OBJ: Demonstrate ability to correctly insert a small-bore feeding tube.

TOP: NG Tube Insertion KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8. The nurse is caring for a patient who is receiving continuous tube feedings. What must the nurse do to care for this patient?

a.

Verify tube position every 4 to 6 hours.

b.

Obtain a radiograph every 4 to 12 hours.

c.

Instill air into the stomach via the tube and listen for bubbles.

d.

Do not worry about tube placement because the tube has already been determined to be in the right place.

ANS: A

After initial radiographic verification that a tube is positioned in the desired site (either the stomach or the small intestine), the nurse is responsible for ensuring that the tube has remained in the intended position before administering formula or medications through the tube. Therefore, the nurse must verify tube position every 4 to 6 hours and as needed. Because it is not practical to do radiographic checks at this frequency, other methods of determining placement have been investigated. Insufflation of air into the tube while the abdomen is auscultated is not a reliable means of determining the position of the feeding tube tip. It is possible for the tip of a feeding tube to move into a different location (from the stomach to the intestine, or from the intestine into the stomach) without any external evidence that the tube has moved. The risk for aspiration of regurgitated gastric contents into the respiratory tract increases when the tip of the tube accidentally dislocates upward into the esophagus.

DIF: Cognitive Level: Application REF: Text reference: p. 782

OBJ: Discuss the rationale for methods used to determine nasogastric or nasoenteric feeding tube placement. TOP: NG Tube Placement

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

9. The home health nurse evaluates the provision of intermittent tube feedings by the patients family member. The nurse notes that additional teaching is required when she notices that the family member:

a.

keeps the formula refrigerated between feedings.

b.

keeps the feeding tube capped between feedings.

c.

begins the feeding before checking tube placement.

d.

irrigates the tube with 30 to 60 mL of water before and after feedings.

ANS: C

For intermittent tube-fed patients, test placement immediately before each feeding and before each administration of medication. Each administration of feeding/medication can lead to aspiration if the tube is displaced. For intermittent feeding, have a syringe ready and be sure that the formula is at room temperature. When tube feedings are not being administered, cap or clamp the proximal end of the feeding tube. Draw up in the syringe 30 mL of normal saline or tap water. This amount of solution will flush the length of the tube.

DIF: Cognitive Level: Application REF: Text reference: pp. 784-785

OBJ: Demonstrate three appropriate techniques for administering enteral formulas.

TOP: Beginning Tube Feedings KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

10. Which evaluation indicates that placement of a nasogastric or enteric tube is correct?

a.

Nasointestinal aspirate with a pH of less than 6

b.

Pleural fluid pH of less than 6

c.

Gastric aspirate with a pH of 5 or less after patient fasting

d.

Gastric aspirate with a pH of 4 and continuous tube feedings

ANS: C

Gastric fluid from a patient who has fasted for at least 4 hours usually has a pH of 5 or less.

Fluid from an enteric tube of a fasting patient usually has a pH greater than 6. The pH of pleural fluid from the tracheobronchial tree is generally greater than 6. Patients with continuous tube feeding may have a pH of 5 or greater.

DIF: Cognitive Level: Analysis REF: Text reference: p. 784

OBJ: Discuss the rationale for methods used to determine nasogastric or nasoenteric feeding tube placement. TOP: NG Tube Placement

KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

11. The nurse is checking the residual volume on a patient who is getting intermittent tube feedings via his NG tube. Which of the following may indicate that the patient has started to bleed again?

a.

The nurse obtains brown aspirate.

b.

The nurse notices that the abdomen is distended.

c.

The nurse obtains red aspirate.

d.

The nurse notices severe respiratory distress.

ANS: C

Red or brown coloring (coffee-grounds appearance) of fluid aspirated from a feeding tube indicates new blood or old blood, respectively, in the gastrointestinal tract. If the color is not related to medications recently administered, notify the physician. Abdominal distention usually indicates that the tube feeding is not progressing through the GI tract. This could be a sign of paralytic ileus. Stop the tube feeding and notify the physician. If the patient develops severe respiratory distress (e.g., dyspnea, decreased oxygen saturation, increased pulse rate), this may be a result of aspiration or tube displacement into the lung. Stop any enteral feedings. Notify the physician. Obtain chest radiographs as ordered.

DIF: Cognitive Level: Analysis REF: Text reference: p. 785

OBJ: Discuss the risk for pulmonary complications during insertion and maintenance of a feeding tube. TOP: NG Tube Placement

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

12. The nurse determines that a nasogastric (NG) tube needs irrigation when she:

a.

obtains more than 200 mL of residual volume.

b.

obtains a small amount of thin watery residual.

c.

does not encounter resistance when aspirating the residual.

d.

obtains a unusually thick secretions.

ANS: D

Thick secretions indicate the need to irrigate the tube. Note the ease with which tube feeding infuses through the tubing. Excess volume of secretions (more than 200 mL) indicates delayed gastric emptying. Irrigating the NG tube will not help. Failure of the formula to infuse as desired may indicate a developing obstruction.

DIF: Cognitive Level: Analysis REF: Text reference: p. 786

OBJ: Demonstrate the appropriate technique for irrigating a feeding tube.

TOP: NG Tube Irrigation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

13. What is an appropriate amount of nasogastric irrigant for an adult patient?

a.

1 or 2 mL

b.

30 mL

c.

5 to 15 mL

d.

250 mL

ANS: B

Draw up 30 mL of normal saline or tap water in a syringe. This amount of solution will flush the length of the tube. Irrigation of a tube requires a smaller volume of solution in children: 1 to 2 mL for small tubes to 5 to 15 mL or more for large ones.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 786

OBJ: Demonstrate the appropriate technique for irrigating a feeding tube.

TOP: NG Tube Irrigation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

14. Which technique is appropriate for providing intermittent tube feeding once placement of the tube has been checked?

a.

Cooling the formula

b.

Lowering the head of the bed

c.

Allowing the bag to empty gradually over 30 to 45 minutes

d.

Adding food coloring to detect aspiration

ANS: C

Allow the bag to empty gradually over 30 to 45 minutes. Gradual emptying of tube feeding by gravity from the feeding bag reduces the risk for abdominal discomfort, vomiting, or diarrhea induced by bolus or too-rapid infusion of tube feedings. Cold formula causes gastric cramping. Place the patient in high-Fowlers position, or elevate the head of the bed at least 30 degrees to prevent aspiration. Do not add food coloring or dye to formula to assist in detecting aspiration, presumably by staining tracheobronchial secretions. This is associated with increased risk for contamination and may cause patient deaths.

DIF: Cognitive Level: Application REF: Text reference: p. 790

OBJ: Demonstrate three appropriate techniques for administering enteral formulas.

TOP: Administering Tube Feedings KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

15. The nurse is preparing to administer an enteral feeding for the patient. The patient has been on enteral feedings for 2 days. The nurse knows that the most appropriate technique for implementing enteral feeding is:

a.

weighing the patient weekly.

b.

measuring the gastric residual every hour.

c.

changing the formula every 12 hours in an open system.

d.

leaving the formula in place in an open system for up to 24 hours.

ANS: C

Maximum hang time for formula is 12 hours in an open system, and 24 to 48 hours in a closed, ready-to-hang system (if it remains closed). Weigh the patient daily until the maximum administration rate is reached and maintained for 24 hours, and then weigh the patient 3 times per week. Check the gastric residual volume. Residual volume should be assessed before each feeding for intermittent feedings.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 791

OBJ: Demonstrate three appropriate techniques for administering enteral formulas.

TOP: Administering Tube Feedings KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

16. The nurse is initiating a continuous tube feeding for a patient who has a gastrostomy tube. Which of the following procedures indicates proper practice?

a.

Allow the container to empty gradually over 60 minutes.

b.

Change the bag every 24 hours.

c.

Do not use water to flush the tube.

d.

Quickly increase the rate of administration.

ANS: B

Rinse the bag and tubing with warm water whenever feedings are interrupted. Use a new administration set every 24 hours. Allowing the container to empty over 30 to 45 minutes is the method used for intermittent administration of tube feedings. Administer water via a feeding tube as ordered or between feedings. This provides the patient with a source of water to help maintain fluid and electrolyte balance and clears the tubing of formula. Gradually advancing the rate of concentration of the tube feeding helps to prevent diarrhea and gastric intolerance to formula.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 791

OBJ: Demonstrate three appropriate techniques for administering enteral formulas.

TOP: Gastrostomy Tube Feedings KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

17. The nurse would anticipate the need for an enteral access device in which of the following patients?

a.

Patient whose bowel sounds have not yet returned after abdominal surgery

b.

Patient who recently suffered a cerebrovascular accident (CVA)

c.

Patient who dislikes the taste of facility meals

d.

Patient who suffers from severe acute dysphagia

ANS: D

A patient who is unable to swallow because of severe acute dysphagia will require an enteral access device to provide adequate nutrition. The patient who suffered a CVA may require an enteral access device if the ability to swallow is affected, but more information would be needed before this option is chosen. A patient whose bowel sounds have not yet returned will remain NPO and may have no need for an enteral access device. Less invasive strategies can be used for the patient who does not like the taste of food provided by the facility.

DIF: Cognitive Level: Evaluation REF: Text reference: pp. 788 -789

OBJ: Identify indications for enteral access devices. TOP: Enteral Access Devices

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. The nurse is caring for a patient with an enteral feeding tube in place. She assesses for pulmonary aspiration as the main complication related to feeding tubes. She is aware of other complications, including which of the following?(Select all that apply.)

a.

Infection

b.

Diarrhea

c.

Tube clogging

d.

Tube dislodgment

ANS: A, B, C, D

The main complication related to feeding tubes is pulmonary aspiration with possible lung compromise. Other complications include misplaced tubes, infection, diarrhea, tube clogging, and tube dislodgment.

DIF: Cognitive Level: Comprehension

REF: Text reference: pp. 782-783 |Text reference: p. 786 |Text reference: pp. 791-792

OBJ: Discuss the rationale for methods used to determine nasogastric or nasoenteric feeding tube placement. TOP: Complications Related to Feeding Tubes

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

2. The nurse, physician, and dietitian collaborate to select an enteral feeding formula for the patient. Their decision should be based on which of the following? (Select all that apply.)

a.

Protein requirements of the patient

b.

Digestive ability of the patient

c.

Amount of lactose required

d.

The patients disease process

ANS: A, B

The nurse, dietitian, and physician collaborate to select an enteral feeding formula based on the patients protein and calorie requirements and digestive ability. Formulas in the United States are sterile and lactose free. Disease-specific formulas are available, but research has not always supported their efficacy.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 775

OBJ: Assess the patient who is to receive enteral tube feedings.

TOP: Enteral Feeding Formulas KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

3. Conditions that increase the risk for spontaneous tube dislocation include which of the following? (Select all that apply.)

a.

Retching/vomiting

b.

Nasotracheal suction

c.

Coughing

d.

Cyanosis

ANS: A, B, C

Conditions that increase the risk for spontaneous tube dislocation include retching/vomiting, nasotracheal suction, and severe bouts of coughing. Cyanosis may be an indicator of displacement but is not a cause.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 783

OBJ: Discuss the rationale for methods used to determine nasogastric or nasoenteric feeding tube placement. TOP: Dislocation of NG Tube

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. The nurse is caring for a patient with a nasogastric tube in place. What interventions would the nurse perform to reduce the risk of clogging the feeding tube? (Select all that apply.)

a.

Use the smallest barrel syringe possible to reduce the pressure in the tube.

b.

Mix medication with feedings to thoroughly dilute the medication.

c.

Flush the tube liberally with water before, between, and after each medication instillation.

d.

Use the largest barrel syringe possible to reduce the pressure in the tube.

e.

Crush solid medications thoroughly and mix them in water before administration.

ANS: C, D, E

Flushing the tube liberally with water before, between, and after each medication instillation will reduce the risk of clogging, as will crushing solid medications thoroughly and mixing them in water before administration. The largest barrel, not the smallest barrel, syringe exerts less pressure and reduces the risk of clogging. Mixing medications with formula is contraindicated because it increases the risk of clogging.

DIF: Cognitive Level: Application REF: Text reference: p. 784 |Text reference: p. 786

OBJ: List strategies to help prevent clogged feeding tubes. TOP: NG Tube Clogging

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

COMPLETION

1. A tube passed through the nose or mouth with the end terminating in the stomach or the small bowel, and used in feeding the patient for short periods is known as a _____________.

ANS:

nasogastric feeding tube

NG feeding tube

A nurse passes a nasogastric (NG) tube through the nose or mouth with the end terminating in the stomach or the small bowel for use in delivering supplemental nutrition or facilitating gastric decompression.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 777 |Text reference: p. 779

OBJ: Assess the patient who is to receive tube feedings. TOP: Nasogastric Feeding Tube

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

2. The nurse is caring for a patient in a chronic vegetative state with inadequate gastric emptying. The nurse would anticipate finding in a ________ tube placed to assist with this patients nutritional needs.

ANS:

jejunostomy

A jejunostomy tube would be appropriate for this patient. A nasally inserted tube would be inappropriate for long-term use; this fact rules out nasogastric and nasoenteric tubes. A tube placed into the stomach would be inappropriate for a patient with inadequate gastric emptying; this fact rules out gastrostomy and nasogastric tubes.

DIF: Cognitive Level: Analysis REF: Text reference: p. 793

OBJ: Compare and contrast use of the nasogastric tube, nasoenteric tube, gastrostomy tube, and jejunostomy tube for nutritional support. TOP: Types of Access Devices

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

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