ATI MENTAL HEALTH PROCTORED EXAM 2021

. The nurse is concerned about pulmonary aspiration when providing the patient with an intermittent tube feeding. Which action is the priority? a. Observe the color of gastric contents. b. Verify tube placement before feeding. c. Add blue food coloring to the enteral formula. d. Run the formula over 12 hours to decrease overload. ANS: B A major cause of pulmonary aspiration is regurgitation of formula. The nurse needs to verify tube placement and elevate the head of the bed 30 to 45 degrees during feedings and for 2 hours afterward. While observing the color of gastric contents is a component, it is not the priority component; pH is the primary component. The addition of blue food coloring to enteral formula to assist with detection of aspirate is no longer used. Do not hang formula longer than 4 to 8 hours. Formula becomes a medium for bacterial growth after that length of time. 29. The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. Which action is best for the nurse to take? a. Instill nonliquid medications without diluting. b. Irrigate the tube with 60 mL of water after all medications are given. Mix all medications together to decrease the number of c. administrations. Check with the pharmacy for availability of the liquid forms of medications. ANS: D Use liquid medications when available to prevent tube occlusion. Irrigate with 30 mL of water before and after each medication per tube. Completely dissolve crushed medications in liquid if liquid medication is not available. Read pharmacological information on compatibility of drugs and formula before mixing medications. 30. The patient has just started on enteral feedings, and the patient is reporting d. abdominal cramping. Which action will the nurse take next? a. Slow the rate of tube feeding. b. Instill c