NURSING 254 - FINAL EXAM|| 83
QUESTIONS AND ANSWERS (GRADED
A+)
Small Bore Feed Tube - ANSWER-placed into stomach or small bowel; used primarily
for feeding or administering meds (EX: Dohoff)
Methods of confirming tube placement - ANSWER-1. x-ray *Best Method*
2. aspirate GI secretions - grassy green, off white, or tan
3. pH of aspirated fluid - acidic 1- 4 (Small intestine - >6, respiratory - > 7)
4. confirm length w insertion
Different types of feeds (3) - ANSWER-1. Bolus - resembles normal feeding pattern;
administered 30-60 min every 3-6 hrs
2. continuous - administered over 24 hrs using kangaroo pump
3. cyclic - given at night for 8 - 16 hrs on pump; allows client to attempt to eat normal
meal during day (monitor fluid status and volume)
Large bore feeding tube - ANSWER-placed into stomach; main purpose of suctioning or
delivering nutrients (EX: NG tubes - Levin, Salem)
-used for preventing nausea, vomiting, and gastric distention following surgery or to
remove stomach contents for analysis
NG Tube (Salem) - ANSWER--more often used in suctioning; blue pigtail allows for air
flow, should NOT pass meds through
Nasointestinal tube - ANSWER-longer tube placed into smaller intestine; used in clients
at risk for aspiration
PEG, PEJ - ANSWER-long term nutritional support (more than 6-8 weeks); placed
surgically through ABD wall into stomach of jejunum
clear liquid diet - ANSWER-short term diet (24-36 hrs); after surgeries or in acute stages
of infection- given to relieve thirst, prevent dehydration, minimize GI tract stimulation
FOODS- water, tea, coffee, clear broths, ginger ale, strained/clear juices, gelatin,
honey, hard candy, popsicles
Full liquid diet - ANSWER-given to pts with GI disturbances or who can't tolerate solid
foods; not long term, low in iron, protein and calories
FOODS - clear liquid diet PLUS foods that turn to liquid at room temp, milk, pudding, ice
cream. refined cereals, butter/cream, peanut butter, yogurt
, soft diet - ANSWER-ordered for clients who have difficulty chewing and or swallowing;
low residue, easily chewed and digested
FOODS - tender meat, scrambled eggs, mild cheeses, mashed/sweet potatoes,
cooked/canned fruit, enriched rice, pasta, breads
-Pureed diet modification of this ---- water added to foods then blended
specific disease diet - ANSWER-prescribed to meet requirements for disease processes
or altered metabolism; some clients (ex: diabetes) may need to follow diet for a lifetime
and should understand/develop a positive about it
dysphagia - ANSWER-may have inadequate solid/fluid intake and have nutritional
problems r/t dysphagia; people @ risk include older adults, cancer pts w head or neck
radiation or cranial nerve dysfunction
enteral nutrition - ANSWER-provided when pt can't ingest foods, or the upper GI tracts
impaired and transport of food to small intestine is impaired; may be at risk for
distention, aspiration, altered fluid intake
Deep tissue damage - ANSWER-looks like a bruise; may be a blister
Prevention of Pressure Ulcers - ANSWER-1. turn pt every 2 hours
2. increase nutritional intake
3. keep pt dry
4. take socks/equipment off when inspecting
5. supportive devices
6. avoid friction/shear when moving
Treatment for Pressure Ulcers - ANSWER--debridement
-irrigation and packing
-topical agents/dressings
-hyperbaric chambers
*reduce/eliminate causative factors - pressure, shear, friction, moisture, neuropathy
-provide systemic support for wound health - nutritional support, topical therapy
local infection - ANSWER-limited to the part of the body where microorganisms are
systemic infections - ANSWER-microorganisms spread, damage different parts of the
body
What do monitor in terms of enteral nutrition - ANSWER--verify tube placement (x-ray)
-keep head elevated
-change container every 24 hours
-don't hang more solution than required for a 24 hour period
-always assess bowel sounds
QUESTIONS AND ANSWERS (GRADED
A+)
Small Bore Feed Tube - ANSWER-placed into stomach or small bowel; used primarily
for feeding or administering meds (EX: Dohoff)
Methods of confirming tube placement - ANSWER-1. x-ray *Best Method*
2. aspirate GI secretions - grassy green, off white, or tan
3. pH of aspirated fluid - acidic 1- 4 (Small intestine - >6, respiratory - > 7)
4. confirm length w insertion
Different types of feeds (3) - ANSWER-1. Bolus - resembles normal feeding pattern;
administered 30-60 min every 3-6 hrs
2. continuous - administered over 24 hrs using kangaroo pump
3. cyclic - given at night for 8 - 16 hrs on pump; allows client to attempt to eat normal
meal during day (monitor fluid status and volume)
Large bore feeding tube - ANSWER-placed into stomach; main purpose of suctioning or
delivering nutrients (EX: NG tubes - Levin, Salem)
-used for preventing nausea, vomiting, and gastric distention following surgery or to
remove stomach contents for analysis
NG Tube (Salem) - ANSWER--more often used in suctioning; blue pigtail allows for air
flow, should NOT pass meds through
Nasointestinal tube - ANSWER-longer tube placed into smaller intestine; used in clients
at risk for aspiration
PEG, PEJ - ANSWER-long term nutritional support (more than 6-8 weeks); placed
surgically through ABD wall into stomach of jejunum
clear liquid diet - ANSWER-short term diet (24-36 hrs); after surgeries or in acute stages
of infection- given to relieve thirst, prevent dehydration, minimize GI tract stimulation
FOODS- water, tea, coffee, clear broths, ginger ale, strained/clear juices, gelatin,
honey, hard candy, popsicles
Full liquid diet - ANSWER-given to pts with GI disturbances or who can't tolerate solid
foods; not long term, low in iron, protein and calories
FOODS - clear liquid diet PLUS foods that turn to liquid at room temp, milk, pudding, ice
cream. refined cereals, butter/cream, peanut butter, yogurt
, soft diet - ANSWER-ordered for clients who have difficulty chewing and or swallowing;
low residue, easily chewed and digested
FOODS - tender meat, scrambled eggs, mild cheeses, mashed/sweet potatoes,
cooked/canned fruit, enriched rice, pasta, breads
-Pureed diet modification of this ---- water added to foods then blended
specific disease diet - ANSWER-prescribed to meet requirements for disease processes
or altered metabolism; some clients (ex: diabetes) may need to follow diet for a lifetime
and should understand/develop a positive about it
dysphagia - ANSWER-may have inadequate solid/fluid intake and have nutritional
problems r/t dysphagia; people @ risk include older adults, cancer pts w head or neck
radiation or cranial nerve dysfunction
enteral nutrition - ANSWER-provided when pt can't ingest foods, or the upper GI tracts
impaired and transport of food to small intestine is impaired; may be at risk for
distention, aspiration, altered fluid intake
Deep tissue damage - ANSWER-looks like a bruise; may be a blister
Prevention of Pressure Ulcers - ANSWER-1. turn pt every 2 hours
2. increase nutritional intake
3. keep pt dry
4. take socks/equipment off when inspecting
5. supportive devices
6. avoid friction/shear when moving
Treatment for Pressure Ulcers - ANSWER--debridement
-irrigation and packing
-topical agents/dressings
-hyperbaric chambers
*reduce/eliminate causative factors - pressure, shear, friction, moisture, neuropathy
-provide systemic support for wound health - nutritional support, topical therapy
local infection - ANSWER-limited to the part of the body where microorganisms are
systemic infections - ANSWER-microorganisms spread, damage different parts of the
body
What do monitor in terms of enteral nutrition - ANSWER--verify tube placement (x-ray)
-keep head elevated
-change container every 24 hours
-don't hang more solution than required for a 24 hour period
-always assess bowel sounds
