NSE211 EXAM QUESTIONS WITH
CORRECT ANSWERS
How are infusions typically started or advanced?
Continuous - Answer- 1. start formula at ordered [ ]
- full strength for isotonic formula or at ordered [ ]
- hypertonic formula started at full strength but slower rate because create pressure
gradient that draws water to intestine and cause diarrhea/cramping
2. begin infusion at designated rate
3. advance rate slowly to target rate if tolerated (no nausea and diarrhea/low gastric
residual)
How is enteral feeding ordered? - Answer- - must be ordered in a rate --> mls/hr
example:
A patient receives an order of an enteral feed as:
Isosource 1.5 @30mls/hr
**Isosource 1.5 is the type of formula feed
**30mls/hr means that the patient will get av olume of 30mls of feed every hour - this
would be an example of a continuous feed
supplies need for nasogastric tube - Answer- - gloves, adhesive tape, saline/water, tube
(8-12 french), lubricant, pH strip
pH strip= check aspiration (low=bad)
saline= patancy (blockage)
what can the nurse perform in this procedure - Answer- nasogastric and orogastric
how to assess patency - Answer- tell patient to breathe from my nose while block other
- signs of nasal obstruction/SOB
- if one obstructed insert in other
which side do you stand on and position of pt - Answer- pt= high flowers 45-90 degrees
nurse= whatever hand is dominant ur on that side
determine length - Answer- - nose to earlobe and then earlobe to lower sterum (xiphoid
process)
, what to instruct pt when inserting - Answer- - tilt head slightly forward
- breathe thru mouth
- swallow while inserting
Enteral Nutrition and Safety - Answer- - elevate head of bed to 30-45
- if lowered bed for procedure, return position back asap
- follow policy for suspending feeding while pt is supine
- if pt on intermittent feed; head of bed elevated for 30-60 min after feed
aspiration risk - Answer- - before feed, ensure tube is correct position and elevated bed
- check gastric residual volume
(common protocol ask to check every 6-8 hrs before bolus feed)
if increase retained volume = risk of aspiration high
- minimize use of sedation and perform oral suctioning frequently
- pt may be prescribed med to improve gastric emptying
tube position safety - Answer- - x-ray confirmation of newly inserted tube
- mark exit site of tube at time of initial x ray and check tube external length to regular
length
- check pH level and colour --> aspiration
colour for stomach - Answer- normal; clear, pale yellow, colourless
abnormal; green, brown, red
colour for intestine - Answer- normal; yellow, green
abnormal; red or black
site care - Answer- - digestive juice = irritate skin
- signs of redness and maceration
- monitor bumper tension and pressure injury
- clean and dry
- skin barrier
- nurse provide assistance --> wound, ostomy or continence
Tube Patency - Answer- - require flush routine
- flush with 30 mls of water every 4 hours during, before or after
- tube should be flush btw med and after all med
- use liquid med
To prevent tube clogging that resultsfrom medication - Answer- - irrigate with water
- avoid soda, cranberry juice
- pancreatic enzyme solution or mech device --> clearing tube
Nursing Management of EnteralNutrition - Answer- - check placement
- assess bowel sound before feeding
CORRECT ANSWERS
How are infusions typically started or advanced?
Continuous - Answer- 1. start formula at ordered [ ]
- full strength for isotonic formula or at ordered [ ]
- hypertonic formula started at full strength but slower rate because create pressure
gradient that draws water to intestine and cause diarrhea/cramping
2. begin infusion at designated rate
3. advance rate slowly to target rate if tolerated (no nausea and diarrhea/low gastric
residual)
How is enteral feeding ordered? - Answer- - must be ordered in a rate --> mls/hr
example:
A patient receives an order of an enteral feed as:
Isosource 1.5 @30mls/hr
**Isosource 1.5 is the type of formula feed
**30mls/hr means that the patient will get av olume of 30mls of feed every hour - this
would be an example of a continuous feed
supplies need for nasogastric tube - Answer- - gloves, adhesive tape, saline/water, tube
(8-12 french), lubricant, pH strip
pH strip= check aspiration (low=bad)
saline= patancy (blockage)
what can the nurse perform in this procedure - Answer- nasogastric and orogastric
how to assess patency - Answer- tell patient to breathe from my nose while block other
- signs of nasal obstruction/SOB
- if one obstructed insert in other
which side do you stand on and position of pt - Answer- pt= high flowers 45-90 degrees
nurse= whatever hand is dominant ur on that side
determine length - Answer- - nose to earlobe and then earlobe to lower sterum (xiphoid
process)
, what to instruct pt when inserting - Answer- - tilt head slightly forward
- breathe thru mouth
- swallow while inserting
Enteral Nutrition and Safety - Answer- - elevate head of bed to 30-45
- if lowered bed for procedure, return position back asap
- follow policy for suspending feeding while pt is supine
- if pt on intermittent feed; head of bed elevated for 30-60 min after feed
aspiration risk - Answer- - before feed, ensure tube is correct position and elevated bed
- check gastric residual volume
(common protocol ask to check every 6-8 hrs before bolus feed)
if increase retained volume = risk of aspiration high
- minimize use of sedation and perform oral suctioning frequently
- pt may be prescribed med to improve gastric emptying
tube position safety - Answer- - x-ray confirmation of newly inserted tube
- mark exit site of tube at time of initial x ray and check tube external length to regular
length
- check pH level and colour --> aspiration
colour for stomach - Answer- normal; clear, pale yellow, colourless
abnormal; green, brown, red
colour for intestine - Answer- normal; yellow, green
abnormal; red or black
site care - Answer- - digestive juice = irritate skin
- signs of redness and maceration
- monitor bumper tension and pressure injury
- clean and dry
- skin barrier
- nurse provide assistance --> wound, ostomy or continence
Tube Patency - Answer- - require flush routine
- flush with 30 mls of water every 4 hours during, before or after
- tube should be flush btw med and after all med
- use liquid med
To prevent tube clogging that resultsfrom medication - Answer- - irrigate with water
- avoid soda, cranberry juice
- pancreatic enzyme solution or mech device --> clearing tube
Nursing Management of EnteralNutrition - Answer- - check placement
- assess bowel sound before feeding
