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The nurse has just started a patient on continuous tube feedings of a full-strength commercial formula at 100 mL/hour using a closed system method and has had six diarrhea stools the first day. Which of the following actions should the nurse plan to take?
- A. Slow the infusion rate of the tube feeding.
- B. Check gastric residual volumes more frequently.
- C. Change the enteral feeding system and formula every 8 hours.
- D. Discontinue administration of water through the feeding tube.
Correct Answer: A
Rationale: Loose stools indicate poor absorption of nutrients and indicate a need to slow the feeding rate or decrease the concentration of the feeding. Water should be given when patients receive enteral feedings to prevent dehydration. When a closed enteral feeding system is used, the tubing and formula are changed every 24 hours. High residual volumes do not contribute to diarrhea.
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The nurse is admitting a patient for electrolyte disorders of unknown etiology. Which of the following findings is most important to report to the health care provider?
- A. The patient's knuckles are macerated.
- B. The patient uses laxatives on a daily basis.
- C. The patient has a history of weight fluctuations.
- D. The patient's serum potassium level is 2.2 mmol/L.
Correct Answer: D
Rationale: The low serum potassium level may cause life-threatening cardiac dysrhythmias and potassium supplementation is needed rapidly. The other information also will be reported because it suggests that bulimia may be the etiology of the patient's electrolyte disturbances, but it does not suggest imminent life-threatening complications.
The nurse is caring for a patient with a body mass index (BMI) of 31 kg/m?², a normal C-reactive protein level, and low transferrin and albumin levels. The nurse will plan patient teaching to increase the patient's intake of foods that are high in which of the following?
- A. Iron
- B. Protein
- C. Calories
- D. Carbohydrate
Correct Answer: B
Rationale: The patient's C-reactive protein and transferrin levels indicate low protein stores. The BMI is in the obese range, so increasing caloric intake is not indicated. The data do not indicate a need for increased carbohydrate or iron intake.
The nurse is caring for a patient who is malnourished and is receiving parenteral nutrition (PN) containing amino acids and dextrose for the past 24 hours. The nurse observes that about 50 mL remain in the PN container. Which of the following actions is best for the nurse to take?
- A. Ask the health care provider to clarify the written PN order.
- B. Add a new container of PN using the current tubing and filter.
- C. Hang a new container of PN and change the IV tubing and filter.
- D. Infuse the remaining 50 mL and then hang a new container of PN.
Correct Answer: B
Rationale: All PN solutions are changed at 24 hours. PN solutions containing dextrose and amino acids require a change in tubing and filter every 72 hours rather than daily. Infusion of the additional 50 mL will increase patient risk for infection. Changing the IV tubing and filter more frequently than required will unnecessarily increase costs. The nurse (not the health care provider) is responsible for knowing the indicated times for tubing and filter changes.
The nurse is caring for a patient who is to have a bolus tube feeding. Which of the following actions should the nurse implement?
- A. Deliver the feeding via a syringe over 15 minutes.
- B. Increase the rate of the tube feeding to deliver the bolus over 5 minutes.
- C. Withhold water by mouth for 30 minutes prior to the bolus feeding.
- D. Question the order as tube feedings are not to be delivered as a bolus.
Correct Answer: A
Rationale: Bolus feedings are typically delivered by gravity via a syringe over approximately 15 minutes when the feeding tube is placed in the stomach. The tube feeding rate would not be increased as the bolus should be delivered by gravity via a syringe. It's important to remember that the patient still needs water (1 mL/cal formula received), and this may be administered at any time that the patient can tolerate it.
The nurse is caring for a comatose patient who is receiving continuous enteral nutrition through a soft nasogastric tube and notes the presence of new crackles in the patient's lungs. In which order will the nurse take the following actions?
- A. Turn off the tube feeding.
- B. Document assessment findings.
- C. Check the tube feeding residual volume.
- D. Notify the patient's health care provider.
Correct Answer: A,C,D,B
Rationale: The assessment data indicate that aspiration may have occurred, and the nurse's first action should be to turn off the tube feeding to avoid further aspiration. The next action should be to check the residual volume because it provides data about possible causes of aspiration. The health care provider should be notified and informed of all the assessment data the nurse has just obtained. Lastly, the nurse documents the assessment findings.