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Week 7 NCO
Week 7 Verifying Feeding tube Placement
| Question | Answer |
|---|---|
| Confirmation of correct tube placement by x-ray examination is done ________. | upon insertion |
| It is ________ to delegate verification of tube placement to NAP. | inappropriate |
| The risk of ________ is increased when the tip of an NI tube accidentally dislocates upward into the stomach. | aspiration |
| A patient has been receiving ranitidine hydrochloride, an H2 receptor antagonist, for treatment of a duodenal ulcer. How may this affect pH testing? | It will increase the gastric pH reading......H2 receptor antagonists, such as ranitidine hydrochloride, reduce the volume of gastric acid secretion and the acid concentration of secretions, thus increasing gastric pH. |
| As long as the patient does not demonstrate respiratory symptoms (choking, coughing, cyanosis), pH testing of aspirate is unnecessary. | False: The absence of signs and symptoms of respiratory difficulty does not ensure nonrespiratory placement, especially in patients with decreased level of consciousness or altered cough and gag reflex. |
| You are planning to verify NG feeding tube placement by pH testing. Which result would indicate that the feeding tube is in the expected location? | pH of 3 |
| Images of stomach acid | 1. Green - stomach contents 2. Clear- Stomach contents 3. Yellow - intestinal contents |
| A nursing student asks the staff nurse why auscultation is not used for verifying feeding tube placement. The nurse's best response is: | "A tube placed in the lungs/pharynx/esophagus sounds like air entering the stomach." ...... The sound created when air is inserted through the feeding tube can be mistaken for correct tube placement, when in reality the tube may be inadvertently placed in |
| A health care provider's order is necessary to verify tube placement by pH testing. | False; Although a health care provider's order is required for insertion and radiological verification of placement, it is unnecessary for routine verification of tube placement by pH testing. Testing the pH of aspirate is an expectation of competent nurs |
| What are some factors that, if present, could place the patient at risk for tube dislodgement? | 1. Retching and or vomiting 2. Harsh coughing 3. Frequent nasotracheal suctioning |
| The NAP reports to you that the patient seems to be having difficulty breathing and appears "a little blue." The feeding tube remains secured with tape, and the infusion pump is not alarming. What action should you take at this time? | Go and assess the patient, turn the feeding off, and notify the health care provider......You should assess the patient and, if the patient is displaying respiratory symptoms, turn the feeding off and notify the health care provider. You should be prepare |
| Identify signs and symptoms of accidental respiratory migration of a feeding tube. (Select all that apply.) | 1. Coughing 2. Choking 3. Decreased pulse oximetry |
| Identify the appropriate times to verify enteral tube placement by pH testing. (Select all that apply.) | 1. Before each intermittent feeding. 2. At least once every 6 hours during continuous feedings. 3. Before administration of medications through the tube. |
| If the nurse suspects the NG feeding tube has migrated, the nurse should: | Stop any enteral feedings and obtain an order for a chest x-ray film to determine placement. |
| The nurse aspirates stomach contents from a newly inserted feeding tube. The nurse is aware the patient has been on the proton pump inhibitor omeprazole. The pH strip reads "3." Where should the nurse expect the x-ray film to identify placement of the fee | in the stomach |
| The nurse observes a confused patient pulling at her NG feeding tube. As the nurse retapes the tube to the bridge of the patient's nose, the nurse notices that the mark on the tube has moved away from the naris. What action should the nurse take? | Advance the tube until the mark is even with the naris and verify correct tube placement. |
| The nurses are discussing feeding tube migration and prevention. Which of the following statements indicates correct understanding? | A feeding tube can enter the airway without causing obvious respiratory symptoms. |
| The nurse suspects the patient’s feeding tube has migrated. Which of the following would indicate the greatest risk related to tube migration? | Dyspnea and decreased oxygen saturation. |
| Which of the following, if exhibited by the patient, may increase the risk for spontaneous enteral tube dislocation? (Select all that apply.) Group of answer choices Nausea. | 1. Vomiting. 2. Nasotracheal suctioning. 3. Altered level of consciousness, agitation. |
Created by:
Brandi Sizemore
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