NUR 134 Test 4 - Questions and Answers (Complete Solutions) Feedings that are delivered at regular intervals, using gravity for instillation or a
... [Show More] feeding pump to administer the formula over a set period of time? 1) intermittent 2) bolus 3) continuous 4) A and B Rationale: While an argument could be made for both A and B but that is not the most correct answer... Feedings which use a syringe to instill the formula quickly in one large amount? intermittent bolus continuous A and B Feedings which permit gradual introduction of the formula into the GI tract, promoting maximal absorption; external feeding pump is needed to regulate the flow of formula? intermittent bolus continuous A and B The risk of reflux and aspiration is greater with which type of feeding? intermittent bolus continuous A and B Feeding intolerance is _______ likely to occur with smaller volumes more less most none of these (volume doesn't play a part in this) (T/F) Administration of a tube feeding can be delegated to nursing assistive personnel or unlicensed assistive personnel. True False Rationale: This can be done sometimes but that depends on State laws. Remember definitive answers like always and never are usually false Prescribed tube feeding formula should be given at what temperature? room body hot cold What area should be assessed before administering a tube feeding? chest abdomen feet none of these Before administering a tube feeding, position the patient with HOB elevated at least _____ degrees or as near normal position for eating as possible? 30 to 45 10 to 20 70 0 Rationale: Remember they should be in a fowler's to semi-fowler's position. How would you like to be positioned? Patients who are considered at high risk for aspiration should be assisted into at least a ___ degree position 20 30 45 70 (upright) Elevating the HOB to 30/45 degrees minimizes the possibility of aspiration into the _______. mouth trachea nostril bronchi Before administering an NGT tube feeding, verify the position of the marking of the tube at the patient's _______; measuring the length of the exposed tube and comparing with the documented length mouth trachea nostril bronchi (T/F) The position of the marking on the tube at the patient's nostril should be assessed each time the tube is used. True False If the nurse is unable to obtain an aspirate specimen, they should reposition the patient and flush the tube with _____ of air 10ml 60ml 30ml 5ml The pH of gastric contents is acidic, less than _____. If the patient is taking an acid-inhibiting agent, the pH range may be ___-___ 5.5, 4-6 4.0, 5-7 3.5, 7-8 5.0, 7-8 pH testing is less useful in _______ feedings since the formula raises the pH and has not been emptied? intermittent bolus continuous A and B ________ can be green, with particles, off-white, or brown if old blood is present gastric fluidphlegm snot intestinal fluid ________ may tends to look clear or straw-colored to a deep golden-yellow color--may be greenish-brown if stained with bile gastric fluid phlegm snot intestinal fluid What is considered the most reliable method for identifying the position of the NG tube? x-ray After ensuring the feeding tube is in place, aspirate all gastric contents with the syringe and measure to check for _________ _______ and then return based on facility policy gastric residual High gastric residual volumes (_____-____ mL or greater) can be associated with high risk for aspiration and aspiration-related pneumonia 200-250 Feedings should be held if residual volumes exceed ______mL on two successive assessments 200 Gastric residual should be checked before each _________ feeding, or every 4-6 hours during a __________ feeding? intermittent, continuous After returning gastric residual, flush the tube with ____ of water for irrigation 10ml 60ml 30ml 5ml Flushing the tube with water prevents ___________ infection occlusion aspiration leaks When using a feeding bag (open system), label the bag and/or tubing with date & time, then hang the bag on IV pole and adjust to about _____ above stomach. Clamp tubing. 1ft 5ft 12in A and C When using a feeding bag (open system), check the expiration date of the formula then cleanse the top of the feeding container with _____________ before opening it. normal saline alcohol wipes disinfectant dry towel When using a feeding bag or large syringe (open system), add ___-____ mL (1-2oz) of water for irrigation to feeding bag when the feeding is almost completed and allow it to run through the tube; clamp tubing immediately after water has been instilled. 30-60 The _________ the syringe (large syringe-open system) is held, the faster the formula flows (regulate rate by height of the syringe) higher lower (T/F) Push formula with syringe plunger during large syringe feedings. True False When using a large syringe, hold the syringe ______ when it has emptied to prevent the formula from back-flowing out of the tube and onto the patient. high low even to insertion Feedings must be disposed within how long? 48hrs 24hrs 3 days 4hrs During an enteral feeding, the patient must stay in an _______ position throughout the feeding. If the patient needs to lie flat temporarily, _______ the feeding. supine, pause prone, pause upright, pause upright, slow When giving enteral feedings, placement of the tube and gastric residual should be checked every _____. day hour 4-6 hours shift change Checking ___________ monitors absorption of the feeding and prevents distention, which could lead to aspiration. gastric residual Checking _______ verifies that the tube has not moved out of the stomach. Placement Observe the patient's response during and after tube feeding and assess the abdomen at least _____ per shift. Once Pain or nausea may indicate _____________, which may lead to vomiting stomach distention Abdominal distention and firmness or regurgitation may indicate ___________ Intolerance After an enteral feeding, have the patient remain in an upright position for at least _______ after the feeding 4 hours 8 hours 1 hour 30 mins What should be used to remove a clog in tubing? cool water, gentle pressure hot water, firm pressure cool water, firm pressure warm water, gentle pressure (T/F) Carbonated sodas and meat tenderizers have been shown effective in removing clogs in feeding tubes True False Rationale: They could actually decrease the longevity of the feeding tubes. Patients should be positioned at a ______ for removal of a NG tube supine position prone position sims position 30-45 degree position Before removing NG tube, check placement, attach syringe and flush with __ mL of water or saline solution or clear with _____ mL of air 10, 50-70 30, 10-50 10, 30-50 50, 10-30 (T/F) To remove a NG tube, instruct patient to take a deep breath and hold it. Quickly & carefully remove the tube while the patient holds breath. True False (T/F) Use of a PEG tube or other type of gastrostomy tube requires an intact, functional GI tract. True False The ordered drug is administered until a discontinuation order is written or until a specified date is reached? standing order routine order prn order stat order Prescribed in anticipation of sudden changes in a patient's condition? standing order routine order prn order stat order The ordered drug is given when a patient needs it? standing order routine order prn order stat order An order that is to be administered immediately, usually written for emergencies or when a patient's condition suddenly changes? standing order routine order prn order stat order 6 Rights of Medication Administration? 1) Right drug, right dose, right position, right time, right patient, right documentation 2) Right drug, right dose, right route/form, right target, right patient, right documentation 3) Right drug, right dose, right route/form, right time, right patient, right documentation 4) Right drug, right dose, right route/form, right time, right room, right documentation Official accepted name of a drug? generic name trade name brand name combo name Name under which a manufacturer markets a medication. It indicates the name is registered and protected by law; its use is restricted to the company that legally owns the name? generic name trade name brand name combo name B and C Rationale: Trade name and Brand name are the same thing. It might even be called manufactured name. How much drug is in what form? dosage drug strength solution strength none of these The liquid resulting from the combination of the solute and the solvent solution Injected into the spinal column? IV ID IT IM Rationale: IV -> Intravenous -> into + "vein" ID -> Intradermal -> into + "dermis" IT -> Intrathecal -> into + "spine" (I remember this as IT is the spine of networking) IM -> Intramuscular -> into + "muscle" Applied to the surface of the skin (local or systemic)? transdermal topical ointment suppository inhalation In patch/disk & applied to skin (systemic)? transdermal topical ointment suppository inhalation Breathed into the respiratory tract by nose/mouth? transdermal topical ointment suppository inhalation Applied to mucosa of eyes, ears, nose, or mouth? transdermal topical ointment suppository inhalation Inserted into a body cavity? transdermal topical ointment suppository inhalation Into the intestines/GI tract? parenteral enteral buccal sublingual Rationale: Enteral means intestines Parenteral -> Par = beyond so beyond or other than intestines or via needle into body buccal -> cheek sublingual -> Sub = under/below + lingual = tongue "lingua is great tasting when prepared correctly ;-)" Injected into the body via needle? parenteral enteral buccal sublingual Rationale: Enteral means intestines Parenteral -> Par = beyond so beyond or other than intestines or via needle into body buccal -> cheek sublingual -> Sub = under/below + lingual = tongue "lingua is great tasting when prepared correctly ;-)" Slowly release a controlled amount of medication into the body over a period of time? syrup elixir sustained release/extended release suspension Rationale: Syrup -> Remember that gooey sticky goodness that you put on your waffles/pancakes... It's sweet because of the sugar Elixir -> is alcohol based - li+quor is needed after nursing tests Sustained release/extended release -> slow release or controlled release of medication Suspension -> Insoluble drug in liquid base "If you suspend something you hang it... Suspension is hanging around in the liquid base." Absorbed by mucosa of mouth (should never be swallowed) parenteral enteral buccal sublingual Rationale: Enteral means intestines Parenteral -> Par = beyond so beyond or other than intestines or via needle into body buccal -> cheek sublingual -> Sub = under/below + lingual = tongue "lingua is great tasting when prepared correctly ;-)" Absorbed under the tongue parenteral enteral buccal sublingual Rationale: Enteral means intestines Parenteral -> Par = beyond so beyond or other than intestines or via needle into body buccal -> cheek sublingual -> Sub = under/below + lingual = tongue "lingua is great tasting when prepared correctly ;-)" [Show Less]