ATI MENTAL HEALTH PROCTORED EXAM

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 d. 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 abdominal cramping. Which action will the nurse take next? a. Slow the rate of tube feeding. b. Instill cold formula to “numb” the stomach. c. Change the tube feeding to a high-fat formula. d. Consult with the health care provider about prokinetic medication. ANS: A One possible cause of abdominal cramping is a rapid increase in rate or volume. Lowering the rate of delivery may increase tolerance. Another possible cause of abdominal cramping is the use of cold formula. The nurse should warm the formula to room temperature. High-fat formulas are also a cause of abdominal cramping. Consult with the health care provider regarding prokinetic medication for increasing gastric motility for delayed gastric emptying. 31. The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the mostlikely cause of the diarrhea? a. Antibiotic therapy b. Clostridium difficile c. Formula intolerance d. Bacterial contamination ANS: C Hyperosmolar formulas can cause diarrhea or formula intolerance. If that is the case, the solution is to lower the rate, dilute the formula, or change to an isotonic formula. Antibiotics destroy normal intestinal flora and disturb the internal ecology, allowing for Clostridium difficiletoxin buildup. However, this takes time (more than 2 hours), and no indication suggests that this patient is on antibiotics. Bacterial contamination of the feeding usually occurs when feedings are left hanging for longer than 8 hours. 32.A patient develops a foodborne disease from Escherichia coli. When taking a health history, which food item will the nurse most likely find the patient ingested? a. Improperly home-canned food b. Undercooked ground beef c. Soft cheese d. Custard ANS: B Undercooked ground beef is the usual food source for Escherichia coli. Botulism is associated with improperly home-canned foods. Soft cheese is the usual food source for listeriosis. Custards are associated with salmonellosis and Staphylococcus. 33. The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take? a. Run lipids for no longer than 24 hours. b. Take down a running bag of TPN after 36 hours. c. Clean injection port with alcohol 5 seconds before and after use. Wear a sterile mask when changing the central venous catheter d. dressing. ANS: D During central venous catheter dressing changes, always use a sterile mask and gloves, and assess insertion sites for signs and symptoms of infection. To avoid infection, change the TPN infusion tubing every 24 hours, and do not hang a single container of PN for longer than 24 hours or lipids longer than 12 hours. 34. The patient is having at least 75% of nutritional needs met by enteral feeding, so the health care provider has ordered the parenteral nutrition (PN) to be discontinued. However, the nurse notices that the PN infusion has fallen behind. What should the nurse do? a. Increase the rate to get the volume caught up before discontinuing. b. Stop the infusion as ordered. c. Taper infusion gradually. d. Hang 5% dextrose. ANS: C Sudden discontinuation of PN can cause hypoglycemia. PN must be tapered off. Usually, 10% dextrose is infused when PN solution is suddenly discontinued. Too rapid administration of hypertonic dextrose (PN) can result in an osmotic diuresis and dehydration. If an infusion falls behind schedule, the nurse should not increase the rate in an attempt to catch up. 35. The patient is on parenteral nutrition and is lethargic. The patient reports thirst and headache and has had increased urination. Which problem does the nurse prepare to address? a. Hyperglycemia b. Hypoglycemia c. Hypercapnia