Nutrition_ungraded_skills

Which assessment finding(s) would the nurse report to the health care provider for a patient who is prescribed aspiration precautions? Select all that apply.

• Choking

• Gagging

• Coughing

• Difficulty swallowing

• Difficulty passing flatus

Answer explanation

Assessment data that requires notification to the health care provider when caring for a patient prescribed aspiration precautions include choking, gagging, coughing, and difficulty swallowing. All of these findings could indicate the patient has aspirated. Difficulty passing flatus may be a finding the nurse would report to the health care provider for another issue but not for aspiration concerns

Which nursing action(s) appropriately identifies a patient prior to inserting a prescribed nasoenteric tube? Select all that apply.

• Asking the patient to state their name and birth date

• Asking the patient if they are "Gene Jones" and to state their date of birth

• Verifying the patient's name and social security number by asking a family member

• Comparing the patient's name and medical record number on the prescription to the ID band

• Asking the patient to compare the medical record number and name to the provider's prescription

Answer explanation

The nurse should verify the patient using two identifiers (i.e., patient's name and birth date or name and medical record number) according to agency policy. This can be accomplished by asking the patient to state their name and birth date or by comparing the patient's name and medical record number on the prescription to the identification band placed on the patient's wrist. Asking the patient if their name is Gene Jones elicits a yes or no answer and is not supported by The Joint Commission because it can result in mistakes. The patient's identity should not be verified by a family member, and the patient should not be asked to compare their medical record number and name to the provider's prescription because this requires the ability to read

Which nursing action is appropriate when providing care to a patient who is prescribed intermittent tube feedings?

• Obtaining an x-ray film after each feeding

• Monitoring tube placement every 4 to 6 hours

• Checking tube placement prior to each feeding

• Flushing the tube with 15 mL of water to avoid clogging

Answer explanation

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. An x-ray film is often obtained to confirm placement prior to the initial tube feeding and before any feeding where the placement of the tube is questioned, but it is not necessary after each feeding. 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, not 15 mL, of water to avoid clogging

Which nursing action promotes safety of a patient who is prescribed continuous enteral feeding?

• Using an infusion pump

• Auscultating for tube placement

• Placing the patient in a supine position

• Using surgical technique when providing patient care

Answer explanation

The nurse should use an infusion pump to promote the safety of a patient who is prescribed continuous enteral feeding. Auscultating to verify tube placement is not reliable enough for enhancing patient safety. The patient should be positioned in an upright, not supine, position to promote safety, and the nurse should use aseptic, not surgical, technique.

the nurse notes a gastric residual volume (GRV) of 260 mL. Which nursing action is the priority?

• Rechecking the GRV in 1 hour

• Consulting with the patient's dietitian

• Placing the patient in a side-lying position

• Discarding the GRV and administering the scheduled feeding

Answer explanation

The priority nursing action in this situation is to hold the feeding and recheck the GRV in 1 hour. The nurse should consult with the patient's health care provider, not the dietitian, in this situation. The patient should be placed in an upright position, not a side-lying position. The GRV should be returned and the feeding held; discarding the GRV can cause fluid and electrolyte imbalances.

Which nursing action is appropriate when administering an enteral feeding to a patient who is diagnosed with pulmonary aspiration secondary to regurgitation of formula?

• Assessing gag reflex

• Repositioning the tube

• Verifying tube placement once per day

• Placing the patient in high-Fowler's position

Answer explanation

The appropriate nursing action for a patient diagnosed with pulmonary aspiration secondary to regurgitation of formula is to place the patient in high-Fowler's position during the feeding and for 2 hours after the feeding is complete. Assessing the gag reflex is an appropriate action for a patient who experiences pulmonary aspiration secondary to a deficient gag reflux, not regurgitation of formula. The tube should be repositioned for a patient who experiences pulmonary aspiration secondary to a displaced tube, not regurgitation of formula. Tube placement should be verified before each intermittent feeding and every 4 to 6 hours for continuous feeding, not once per day.

Which skill would the nurse delegate to assistive personnel when providing care to a patient receiving enteral feedings?

• Inserting the patient's tube

• Checking the patient's tube placement

• Positioning the patient during insertion

• Aspirating gastric content from the patient

Answer explanation

The nurse can delegate patient positioning during insertion to the nursing assistive personnel. Tube insertion, checking tube placement, and aspirating gastric content are tasks that nurses and health care providers must handle.

Which statement by the nurse exemplifies the teach-back method to determine patient and family understanding regarding dysphagia?

• How do you currently prevent choking?

• Aspiration is life threatening and should be taken seriously. Do you know the Heimlich maneuver?

• Now that I have explained dysphagia and choking prevention to you, I expect you to share this information with your family.

• I want to be sure I properly explained dysphagia and how to prevent choking. Can you explain to me why these steps protect you from choking?

Answer explanation

The teach-back method is used to evaluate understanding of patient teaching related to any topic, including aspiration prevention and dysphagia. Stating to the patient that the nurse wants to be sure dysphagia and choking prevention were explained adequately and then asking the patient to explain the steps to protect against choking exemplifies this method; it allows the nurse to revise instruction or develop a plan for revised patient teaching if needed. Asking how the patient prevents choking and if they know the Heimlich maneuver can be used to assess patient understanding, but does not ask the patient to teach back what hey have learned. Telling the patient to relay information to their family does not assess understanding, which is a goal of the teach-back method. 

Which nursing action is appropriate for a patient with a gastric aspirate of 150 mL?

• Return all the aspirate.

• Discard all the aspirate.

• Notify the health care provider.

• Dilute the aspirate with water and return.

Answer explanation

The appropriate nursing action for a patient with a gastric aspirate of 150 mL is to return all the aspirate to the patient. Discarding all the aspirate could lead to fluid and electrolyte imbalances. Notifying the health care provider of this amount of aspirate is not necessary. Diluting the aspirate with water and returning it to the patient could lead to fluid and electrolyte imbalances.

Which equipment would the nurse have available when assessing the pH of gastric aspirate?

• Sterile gloves

• pH indicator strip

• Stethoscope

• Sterile normal saline

Answer explanation

The nurse should have a pH indicator strip available when assessing the pH of gastric aspirate. The other supplies listed are not required to assess the pH of gastric aspirate.