A nurse has to administer liquid nourishment to a client over 30-60 minutes at the rate of 250-400 mL per administration with a feeding pump. Which of the following tube-feeding cycles should the nurse follow? Show a. Intermittent feeing b. Cyclic feeding c. Continuous feeing d. Bolus feeding- A Intermittent feeding involves the gradual instillation of liquid nourishment 4-6 times a day, whereas a bolus feeding involves the instrillation of liquid noursihment 4-6 times a day in less than 30 minutes. A cyclic feeding is the continuous instillation of liquid nourishment for 8-12 hours, and a continuous feeding schedule is the instillation of liquid nutrition without interruption. A nurse needs to insert a nasointestinal tube inside the nostril of a client. Whicho f the following should the nurse ask the client to perform when assessing each nostril? a. Use a nebulizer for half an hour b. Perform presurgical skin preparation c. Avoid clearing nasal debris d. Ask the client to exhale D The nurse should ask the client to exhale when each nostril, in turn, is occluded. The nurse should ask the client to clear nasal debris by clowing into a paper tissue. Presurgical skin preparation is not done to the nose before the insertion of a nasointestinal tube. Asking the client to perform nebulization is not corect because that is done when the client is having respiratory problems. The nurse inspects each nostril for size, shape, and patency only after the client has finished clearing nasal debris A nurse has to insert an intestinal decompression tube from the pyloric valve into the small intestine of a client. Which of the following actions should the nurse perform? a. Observe the graduated marks on the tube b. Move the client into the Fowler's position c. Ambulate the client if possible d. Request an X-ray confirmation C Ambulation helps the tube move through the pyloric valve into the small intestine. Moving the client into the Fowler's position for 2 hours on both sides promotes movement through intestinal curvess. Observing the graduated marks on the tube enables monitoring of the tube's progression and opproximate anatomic location. A radiograph is obtained when the tube has reached the prescribed distance. A nurse as to remove an intesinal decompression tube from a client. Which of the following actions should the nurse perform first when removing an intesinal decompression tube? a. Remove the tube within 10 minutes b. Disconnect the tube from the suction source c. Secure the tube to the face with tape d. Verify the tube placement with a radiograph B 1st disconnect from the suction source. Next the tape is removed and the tube is withdrawn 6-10 inches at 10 minute intervals. When the last 18 inchesremains, the tube is pulled gently from the nose. A radiograph is obtained to verify the correct placement when it is being inserted in the client, not when it is being removed A nurse is performing a preintubation assessment for a client who has been prescribed a nasogastric tube. Which of the following is the main goal of the assessment? a. Determine whether there is any nausea and vomiting b. Determine the client's ability to swallow, cough, and gag c. Detect the nostril best suited for tube insertion d. Check the client's level of consciousness C The main goal of preintubation assessment is to determine which nostril is most suitable for inserting the tube. Determining whether there is any nausea and vomiting; the ability to swallow, cough, and gag; or even checking the level of consciousness are different contributing factors of preintubation assessment, not the main goal. A nurse is inserting a gastric sump tube inside a client. Which of the following activities is most suitable with the use of a gastric sump tube? a. Removes fluid and gas from the stomach b. Provides nourishment to the small intestine c. Removes liquid contents from the small intestine d. Reduces trauma to intestinal tissue A Gastric sump tubes are used exclusively for removing fluid and gas from the stomach. Nasointestinal tube, not gastric sump tubes, are used to provide nourishment and to remove has and liquid contents from the small intestine. Intestinal decompression tubes reduce trauma to intesinal tissue A nurse is caring for a client who is provided with liquid noursihment on a cyclic feeding schedule. Which of the following times is most suitable for tube-feeding the client? a. Early morning b. Afternoon c. Late evening d. After lunch C In cyclic feeding, the tube feeding is given to clients during the late evening and sleep because, during the day, clients eat some food orally. As oral intake increases, the volume and duration of the tube feeing gradually are decreased. Cyclic feeding isuse to wean clients from tube feedings when continuing to maintain adequate nutrition A nurse is checking the gastric residual of a client who is being tube-fed. As a rule of thumb, how much should the volume of gastric residual be? a. Less than 250 mL b. Approximately 150 mL c. 1 mL/kcal, on a daily basis d. No more than 100 mL D As a rule of thumb, the gastric residual should be no more than 100 mL or no more than 20% of the previous hour's tube-feeding volume. If the gastric residual is more than 100 mL, overfilling the stomach can cause gastric reflux, regurgitation, vomiting, aspiration, and pneumonia A physician has ordered a nurse to provide enteral nutrition to a client. Which of the following actions should the nurse perform to provide enteral nutrition? Select ALL that apply. a. Provide nourishment via stomach b. Administer a liquid tube-feeing formula c. Provide noursihment via the intestine d. Use a tube that is hort in length e. Use a tube that is small in diameter A, B, C Enteral nutrition is provided via the stomach or small intesine rather than by the oral route by a liquid tube-feeding formula. Although a nasogastric tube can be used, it is more likely that liquid formula will be administerd through a nasointestinal or a transabdominal tube, which is longer in length and smaller in diameter A nurse is preparing a home care not for a tube-fed client who is being discharged from the health care facility. Which of the following points is most important when preaparing clients to take care of themselves at home? a. Demonstrate each procedure b. Provide detailed written instructions c. Make a referral to a home health agency d. Teach self-administration techniques B Before demonstrating the procedure, the nurse should provide detailed written instructions that include the names and contact numbers in case of an emergency, among other things. In addition, depending on the client's seelf-confidence and competence in self-administering tube feedings, health care providers often make a referral to a home health agency for post-discharge nursing support. A nurse is inserting an intestinal decompression tube inside a client. Which of the following actions will help the nurse to monitor the tube's progression and approximate anatomic location? a. Observe graduated marks on the tube b. Reinsert the stylet when the tube is inside c. Ambulate the client if possible d. Mark the tube before inserting A To monitor the tube's progression and apporximate anatomic location, the nurse should observe the graduated marks on the tube. Following the markings on the tube before inserting manually will not provide the tube's anatomic location. Never reinsert the stylet when the tube is in the client because reinsertion might cause trauma to the client and damage to the tube. Ambulation helps the tube to move through the pyloric valve into the small intestine. A nurse is assessing a feeding tube smaller than 12 Fr, which is prone to obstruction. Which of the following actions should the nurse perform to maintain tube patency? Select ALL that apply a. Wash the tube every 2 hours b. Give plenty of water to the client c. Flush the tube with 30-60 mL water d. Flush the tube with cranberry juice e. Flush the tube with carbonated beverages C It is best to flush feeding tubes with 30-60 Ml water emmediately before and after administering a feeding or meds, every 4 hours if the client is being continuously fed, and after refeeding the gastric residual. Giving ice chips or occasional sips of water to a client who is otherwise not taking food orally promotes tube patency. Sparingly because water is hypotonic and draws electrolytes into the gastric fluid. Cranberry and carbonated beverages are used as flushing solutions, although water is best. Formula tends to curdle with cranberry juice A nurse has to tube-feed a client. Which of the following tube-feeding schedules is least desirable because it distends the stomach rapidly, causes gastric discomfort, and increases risk of reflux? a. Continuous b. Bolus c. Intermittent d. Cyclic B A bolus feeding schedule is the least desirable because it distends the stomach rapidly, causing gastric discomfort and the increased risk of reflux. Intermittent feedings fill the stomach gradually, at a slower rate, thereby reducing the bloated feeling. A cyclic feeding is used to wean the client from tube feedings. A continuous feeding is administered at a rate of approximately 1.5 mL/minute. Continuous feeding creates some inconvenience, because the pump must go wherever the client goes. A nurse is rectifying a gastrostomy leak that has occurred in a feeding tube inserted in a client. Which of the following are causes of a gastrostomy leak? Select ALL that apply. a. Infusion of the feed when the gastrointestinal tube is clamped b. Reduction in abdominal pressure c. Disconnection between the feeding tube and the gastrointestinal tube d. Instillation of highly concentrated nutritional formula e. Underinflation of the balloon beneath the skin A, C, E When a client is administered with tube-feeding formula, the pressure on the abdomen is increased, not reduced, which could lead to gastrostomy leaks (not the main cause). Instillation of highly concentrated nutritional formula does not cause gastrostomy leaks, but leads to hydration. A client with a nasogastric tube complains of vomiting sensation. The nurse assesses the client and notices that the client's bowel sounds are less than five per minute. Which of the following nursing diagnoses should the nurse document based on the data collected during client care? a. Imbalanced nutrition b. Self-care deficit c. Impaired swallowing d. Risk for aspiration D Because the client is complaining of a vomiting feeling, and the nurse has confirmed that the client's bowel sounds are less than five per minute, the nurse should identify it as risk for aspiration. The client is not discharged or eating independently, so self-care deficit is not applicable. The cilent does not have any problem with the prescribed nurtition formula or swallowing it, so a nursing diagnosis for imbalanced nutrition and impaired swallowing would be incorrect A nurse is administering a tube feeding to a client. The nurse pinches the feeding tube just as the last volume of water is administered. Which of the following reasons is most appropriate for the nurse's actions? a. To provde access to formula b. To prevent the tube from leaking c. To prevent air from entering the tube d. To purge air from the tube C To prevent air from entering the tube, the nurse pinches the feeding tube just as the last volume of water is administered. To prevent leaking, the nurse should clamp or unplug the feeding tube. To provide access to formula, the nurse should connect the tubing to a nasogastric or nasoenteral tube. The gradual opening of the clamp on the tubing helps to purge air from the tube. A nurse is caring for a tube-fed client who has inflammation of the middle ear. Which of the following nursing interventions will reduce the infalmmation? a. Insert a small-diameter feeding tube b. Provide nasal and oral hygiene c. Keep the tubing filled with water d. Maintain the client's necl in a neutral position A Middle ear inflammation is caused by the narrowing or obstruction of the eustachian tube from the presence of a tube in pharynx. The nurse provides nasal and oral hyfiene when the client's oral and nasal mucous membranes are dry. The client's neck is maintained in a neutral position when there is a plugged feeding tube. resulting from a kinked tube. Tubing is filled with water when there is air in the stomach, and the client complains of nausea and vomiting How do I advance my tube feeding rate?Advance the rate of feeding 25 cc per hour every 12 hours as tolerated until desired rate is achieved (usually 75 to 100 cc per hour). Do not exceed desired rate recommended by dietitian. Convert to interval feedings 48 hours after desired continuous rate is achieved.
How do you administer intermittent tube feeding?In cyclic feeding, EN is administered via a feeding pump in less than a 24-h time period. In intermittent feeding, EN is administered over 20-60 min every 4-6 h with or without a feeding pump. In bolus feeding, EN is administered via a syringe or gravity drip over a 4-10-min period.
What are nursing considerations when administering an enteral feeding?When beginning enteral feedings, monitor the patient for feeding tolerance. Assess the abdomen by auscultating for bowel sounds and palpating for rigidity, distention, and tenderness. Know that patients who complain of fullness or nausea after a feeding starts may have higher a GRV.
When would the nurse change the equipment used for administering enteral feeding via continuous tube feeding?The set should be changed every 24 hours or as per manufactures instructions.
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Which nursing action is appropriate when advancing the rate of an intermittent tube feeding?
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