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Questions and Answers
A client with a history of stroke is at increased risk for aspiration. Which assessment finding would be most indicative of silent aspiration?
A client with a history of stroke is at increased risk for aspiration. Which assessment finding would be most indicative of silent aspiration?
- Frequent throat clearing and congestion during eating.
- A persistent low-grade fever without any other apparent cause. (correct)
- Sudden onset of wheezing and coughing after swallowing.
- Complaints of heartburn and chest discomfort post-meals.
A nurse is caring for a client with dysphagia. Which characteristic of thickened liquids is most important to verify before the client consumes them?
A nurse is caring for a client with dysphagia. Which characteristic of thickened liquids is most important to verify before the client consumes them?
- The liquid is clear and free of any visible particles.
- The liquid has a slightly sweet taste to encourage consumption.
- The liquid has reached the consistency prescribed by the provider. (correct)
- The temperature of the liquid is between 60-70°F.
A client receiving tube feedings exhibits a sudden onset of increased respiratory rate, decreased oxygen saturation, and audible wheezing. What is the priority nursing intervention?
A client receiving tube feedings exhibits a sudden onset of increased respiratory rate, decreased oxygen saturation, and audible wheezing. What is the priority nursing intervention?
- Repositioning the client to a supine position to ease breathing.
- Increasing the rate of the tube feeding to compensate for potential nutrient loss.
- Immediately stopping the tube feeding. (correct)
- Administering a bronchodilator medication.
Which action is most important for the nurse to take when delegating feeding assistance to assistive personnel (AP) for a client at risk for aspiration?
Which action is most important for the nurse to take when delegating feeding assistance to assistive personnel (AP) for a client at risk for aspiration?
A client with dysphagia is using the chin-tuck swallowing technique. How does this technique reduce the risk of aspiration?
A client with dysphagia is using the chin-tuck swallowing technique. How does this technique reduce the risk of aspiration?
For a client with dysphagia who has weakness on their left side, which swallowing technique would be most appropriate?
For a client with dysphagia who has weakness on their left side, which swallowing technique would be most appropriate?
A client who does not have diabetes has a fasting blood glucose level of 60 mg/dL. Which of the following is the most appropriate initial nursing action?
A client who does not have diabetes has a fasting blood glucose level of 60 mg/dL. Which of the following is the most appropriate initial nursing action?
A nurse is teaching a parent about managing their child's hypoglycemia. The child typically needs 10 grams of carbohydrates to correct low blood sugar. Which snack would be most appropriate?
A nurse is teaching a parent about managing their child's hypoglycemia. The child typically needs 10 grams of carbohydrates to correct low blood sugar. Which snack would be most appropriate?
Which of the following best describes the role of glucagon in blood glucose regulation?
Which of the following best describes the role of glucagon in blood glucose regulation?
A client's blood glucose is 350 mg/dL prior to lunch. The provider orders 8 units of regular insulin to be administered subcutaneously. When should the nurse administer this insulin?
A client's blood glucose is 350 mg/dL prior to lunch. The provider orders 8 units of regular insulin to be administered subcutaneously. When should the nurse administer this insulin?
A nurse is preparing to administer insulin to a client. Which action is most important to ensure accurate dosing?
A nurse is preparing to administer insulin to a client. Which action is most important to ensure accurate dosing?
A client with diabetes is receiving long-acting insulin. When should the nurse expect this type of insulin to start working?
A client with diabetes is receiving long-acting insulin. When should the nurse expect this type of insulin to start working?
Which client condition would be a contraindication for the placement of a gastrostomy tube (G-tube)?
Which client condition would be a contraindication for the placement of a gastrostomy tube (G-tube)?
What is the priority nursing action to confirm the correct placement of a nasogastric (NG) tube immediately after insertion?
What is the priority nursing action to confirm the correct placement of a nasogastric (NG) tube immediately after insertion?
Which of the following clients would benefit from the placement of a nasojejunal (NJ) tube rather than a nasogastric (NG) tube?
Which of the following clients would benefit from the placement of a nasojejunal (NJ) tube rather than a nasogastric (NG) tube?
What is the primary reason enteral nutrition is preferred over parenteral nutrition when a client has a functional GI tract?
What is the primary reason enteral nutrition is preferred over parenteral nutrition when a client has a functional GI tract?
A nurse is preparing to administer a bolus feeding via a nasogastric tube. After checking the client's residual volume, the nurse obtains 300 mL. What is the most appropriate nursing action?
A nurse is preparing to administer a bolus feeding via a nasogastric tube. After checking the client's residual volume, the nurse obtains 300 mL. What is the most appropriate nursing action?
A client receiving continuous enteral feedings develops diarrhea. Which of the following actions should the nurse consider first?
A client receiving continuous enteral feedings develops diarrhea. Which of the following actions should the nurse consider first?
What lab result will be most important to monitor routinely in a client receiving total parenteral nutrition (TPN)?
What lab result will be most important to monitor routinely in a client receiving total parenteral nutrition (TPN)?
A client receiving parenteral nutrition exhibits signs of fluid overload, such as edema and increased blood pressure. Which adjustment to the TPN order should the nurse anticipate?
A client receiving parenteral nutrition exhibits signs of fluid overload, such as edema and increased blood pressure. Which adjustment to the TPN order should the nurse anticipate?
A nurse is assisting a client with mealtime. Which action demonstrates appropriate aspiration precautions?
A nurse is assisting a client with mealtime. Which action demonstrates appropriate aspiration precautions?
The nurse observes a client coughing frequently while eating. What is the immediate priority?
The nurse observes a client coughing frequently while eating. What is the immediate priority?
When assisting a client with one-sided weakness from a stroke, how should the nurse position the client during feeding?
When assisting a client with one-sided weakness from a stroke, how should the nurse position the client during feeding?
Which type of assistive device is designed to help clients maintain independence while eating?
Which type of assistive device is designed to help clients maintain independence while eating?
A client with dysphagia has been prescribed honey-thick liquids. What characteristic defines this consistency?
A client with dysphagia has been prescribed honey-thick liquids. What characteristic defines this consistency?
A client who has undergone a gastrectomy is now ordered to start taking liquids. What is the most important consideration when initiating oral feedings?
A client who has undergone a gastrectomy is now ordered to start taking liquids. What is the most important consideration when initiating oral feedings?
What is the primary purpose of checking gastric residual volume before administering enteral feeding?
What is the primary purpose of checking gastric residual volume before administering enteral feeding?
A client on TPN develops a fever, chills, and elevated white blood cell count. What is the most likely cause?
A client on TPN develops a fever, chills, and elevated white blood cell count. What is the most likely cause?
Which insulin has the fastest onset of action?
Which insulin has the fastest onset of action?
When teaching a client how to administer insulin, what is the most important point to emphasize regarding injection sites?
When teaching a client how to administer insulin, what is the most important point to emphasize regarding injection sites?
Which best describes a percutaneous endoscopic gastrostomy (PEG) tube?
Which best describes a percutaneous endoscopic gastrostomy (PEG) tube?
A client receiving enteral feedings via a gastrostomy tube develops abdominal distension and reports nausea. What is the most appropriate initial nursing intervention?
A client receiving enteral feedings via a gastrostomy tube develops abdominal distension and reports nausea. What is the most appropriate initial nursing intervention?
A nurse is caring for a client receiving TPN through a central venous catheter. What nursing intervention is most important to prevent infection?
A nurse is caring for a client receiving TPN through a central venous catheter. What nursing intervention is most important to prevent infection?
How does the supraglottic swallow technique help prevent aspiration?
How does the supraglottic swallow technique help prevent aspiration?
Which of the following is LEAST likely to lead to aspiration?
Which of the following is LEAST likely to lead to aspiration?
A client with diabetes is prescribed 12 units of insulin lispro (Humalog) before lunch. Knowing that this is rapid-acting insulin, the nurse should administer this medication:
A client with diabetes is prescribed 12 units of insulin lispro (Humalog) before lunch. Knowing that this is rapid-acting insulin, the nurse should administer this medication:
What is the underlying purpose of rotating injection sites when administering insulin?
What is the underlying purpose of rotating injection sites when administering insulin?
A client with a history of stroke is being assessed for dysphagia. Which assessment finding would be most indicative of overt aspiration?
A client with a history of stroke is being assessed for dysphagia. Which assessment finding would be most indicative of overt aspiration?
A nurse is caring for a client with dysphagia who has been prescribed thickened liquids. Which instruction is most important to give to the assistive personnel (AP) who will be assisting with the client's meals?
A nurse is caring for a client with dysphagia who has been prescribed thickened liquids. Which instruction is most important to give to the assistive personnel (AP) who will be assisting with the client's meals?
A client is receiving enteral feedings via a nasogastric tube. The nurse auscultates coarse crackles in the client's lung bases. What is the most appropriate initial nursing action?
A client is receiving enteral feedings via a nasogastric tube. The nurse auscultates coarse crackles in the client's lung bases. What is the most appropriate initial nursing action?
A client with dysphagia is being taught the chin-tuck swallowing technique. Which statement indicates that the client understands the purpose of this technique?
A client with dysphagia is being taught the chin-tuck swallowing technique. Which statement indicates that the client understands the purpose of this technique?
The nurse is caring for a client with left-sided weakness due to a stroke and is at risk for aspiration. Which intervention is the most appropriate to implement during meal times?
The nurse is caring for a client with left-sided weakness due to a stroke and is at risk for aspiration. Which intervention is the most appropriate to implement during meal times?
A client with diabetes has a blood glucose reading of 50 mg/dL. The client is conscious and alert. Which of the following is the most appropriate initial nursing intervention?
A client with diabetes has a blood glucose reading of 50 mg/dL. The client is conscious and alert. Which of the following is the most appropriate initial nursing intervention?
A nurse is teaching a family about managing a child's hypoglycemia. The child typically requires 10 grams of carbohydrates to correct a low blood sugar. Which snack would be most appropriate?
A nurse is teaching a family about managing a child's hypoglycemia. The child typically requires 10 grams of carbohydrates to correct a low blood sugar. Which snack would be most appropriate?
A client's blood glucose is 280 mg/dL before dinner. The provider orders 6 units of lispro (Humalog) to be administered subcutaneously before the meal. When should the nurse administer this insulin?
A client's blood glucose is 280 mg/dL before dinner. The provider orders 6 units of lispro (Humalog) to be administered subcutaneously before the meal. When should the nurse administer this insulin?
A nurse is preparing to administer insulin to a client. Which action will minimize the risk of lipohypertrophy?
A nurse is preparing to administer insulin to a client. Which action will minimize the risk of lipohypertrophy?
A client is receiving a continuous infusion of enteral nutrition through a gastrostomy tube. The nurse notes the client is experiencing frequent, watery stools. What is the most appropriate initial nursing intervention?
A client is receiving a continuous infusion of enteral nutrition through a gastrostomy tube. The nurse notes the client is experiencing frequent, watery stools. What is the most appropriate initial nursing intervention?
Before administering a bolus enteral feeding, the nurse aspirates 200 mL of gastric residual volume. Which action should the nurse take next?
Before administering a bolus enteral feeding, the nurse aspirates 200 mL of gastric residual volume. Which action should the nurse take next?
A client receiving TPN complains of thirst, headache, and frequent urination. What is the most appropriate initial nursing action?
A client receiving TPN complains of thirst, headache, and frequent urination. What is the most appropriate initial nursing action?
A nurse is caring for a client receiving continuous TPN. The TPN solution runs out, and a new bag is not immediately available. What is the most appropriate intervention?
A nurse is caring for a client receiving continuous TPN. The TPN solution runs out, and a new bag is not immediately available. What is the most appropriate intervention?
A client with dysphagia is prescribed honey-thick liquids. Which characteristic best describes this consistency?
A client with dysphagia is prescribed honey-thick liquids. Which characteristic best describes this consistency?
A client is being discharged home with a gastrostomy tube (G-tube) for continuous enteral feedings. Which statement indicates the best understanding of G-tube care?
A client is being discharged home with a gastrostomy tube (G-tube) for continuous enteral feedings. Which statement indicates the best understanding of G-tube care?
Flashcards
Aspiration
Aspiration
When food, liquid, or other materials enter the lungs instead of air.
Overt Aspiration
Overt Aspiration
Aspiration that presents with noticeable symptoms like coughing or wheezing.
Silent Aspiration
Silent Aspiration
Aspiration with no obvious symptoms.
Thickened Liquids
Thickened Liquids
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Fasting Blood Glucose
Fasting Blood Glucose
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Hypoglycemia
Hypoglycemia
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Gastrostomy Tube (G-tube)
Gastrostomy Tube (G-tube)
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Nasogastric (NG) tube
Nasogastric (NG) tube
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Nasojejunal (NJ) Tube
Nasojejunal (NJ) Tube
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Enteral Nutrition
Enteral Nutrition
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Parenteral Nutrition
Parenteral Nutrition
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Partial Parenteral Nutrition
Partial Parenteral Nutrition
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Total Parenteral Nutrition
Total Parenteral Nutrition
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Assistive Devices
Assistive Devices
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Chin-tuck Position
Chin-tuck Position
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Study Notes
Preventing Aspiration
- Aspiration happens when food, liquid, or other materials enter the lungs instead of air.
- Those with dysphagia or poor swallowing reflexes are prone to aspiration.
- Medical conditions such as stroke, acid reflux, mouth sores, and dental issues increase the risk of aspiration.
- Overt aspiration presents with symptoms like sudden cough, wheezing, trouble breathing, congestion, heartburn, throat clearing, or chest discomfort.
- Silent aspiration occurs without obvious symptoms.
Diet Modification
- Thickening liquids with gels or powders can help prevent aspiration.
- Thinner liquids are easier to aspirate.
- Thickened liquids can be mildly thick (nectar), moderately thick (honey), or extremely thick (pudding).
- Thickness should be verified by stirring and tilting the spoon to check the liquid's flow.
- Liquids like milk, tea, water, coffee, soup, juice, and nutritional supplements can be thickened.
Nurse Assessment
- Nurses should assess clients at risk for dysphagia.
- If aspiration symptoms are noted, clients should be placed on NPO status and the provider should be notified.
- Manifestations of aspiration includes, decreased oxygen saturation, increased heart rate, blood pressure, and respiratory rate, along with audible wheezing.
- To protect clients from aspiration during tube feeding: verify initial tube placement with an x-ray before use.
- Check tube placement every 4 hours by checking the pH of the gastric contents.
- Check tube feeding tolerance every 4 hours by measuring the residual; follow facility policy for residuals over 250 mL.
- Maintain the head of the bed at 30° to 45° during feeding and for at least 1 hour after bolus feedings.
- Manifestations indicating tube feeding aspiration include difficulty breathing, wheezing, productive cough, or a fever of 38°C (100.4°F).
- If these manifestations occur, stop the tube feeding and immediately notify the provider.
Assisting with Eating and Feeding
- Health care teams must ensure clients get the eating and drinking assistance they need; The goal is to provide nutritional support and prevent complications.
- RNs must assess clients’ ability to safely swallow before delegating feeding responsibilities.
- The nurse's role includes assisting with food choices, assessing chewing and swallowing abilities, and determining the support level needed.
- Encourage clients to feed themselves if possible to promote independence and note if they require assistive equipment.
- Before the meal, position the client upright in a chair at 90° to prevent aspiration, or raise the head of the bed to 90° with pillows for support.
- Consider if the client needs to use the restroom, wash hands, needs dentures or hearing aids secured.
- Ensure the surroundings are free of clutter.
- Cut food into bite-sized pieces.
Swallowing Techniques
- Speech therapists should teach swallowing techniques to decrease aspiration risk.
- Clients with dysphagia or aspiration risk should be referred for a swallowing evaluation.
- The speech therapist will determine which technique is appropriate.
- Chin-tuck position: Client holds the chin down to the chest while swallowing to narrow the airway's entrance.
- Rotation of the head to the affected side: directs food to the strong side.
- Tilting the head to the strong side: pushes food down that side.
- Supraglottic swallow: Client swallows food/liquid while holding breath, then coughs immediately after to remove residual food, steps include holding the breath while swallowing up to three times.
- Mendelsohn maneuver: Client swallows, holds the swallow for 2–3 seconds, completes the swallow, and then relaxes.
Glucose Monitoring
- Glucose is the primary sugar in the blood, derived from food, and the body’s major energy source.
- Blood glucose monitoring determines a client’s glucose level.
- It is routinely performed for clients with diabetes, but can be done for any client.
- Glucose monitoring can be done at the bedside by obtaining a capillary blood sample and testing it using a glucose meter.
- Blood glucose monitoring is an important tool for clients who have diabetes to evaluate changes in blood glucose level.
- Other reasons to check blood glucose levels include tracking treatments, determining how diet affects glucose levels, and monitoring the effect of sickness or stress.
- Common times to check blood glucose levels include before or after meals/exercise, before bed, during illness, with new medications, or when daily routines change.
- A fasting blood glucose is taken after a client has been NPO for at least 8 hours.
- The expected reference for a fasting blood glucose level for a client without diabetes is 70 to 110 mg/dL.
- A blood glucose level of less than 140 mg/dL after eating 2 hours ago is considered within the expected reference range.
- Hypoglycemia, or low blood glucose, occurs when the blood glucose level is less than 70 mg/dL.
- Treatment for hypoglycemia aimed at increasing the blood glucose level back to the expected reference range.
- Provide 15 g of carbohydrates, such as glucose tablets or gel, 4 ounces of regular soda or juice, 1 tablespoon of honey, or hard candy.
- Recheck blood glucose after 15 min; repeat until the blood glucose level is at least 70 mg/dL.
- Once normal, a meal or snack should be eaten to ensure it doesn’t lower again.
- Young children usually need less than 15 grams of carbohydrates to fix a low blood glucose level; with infants needing 6 g, toddlers 8 g, and small children 10 g.
Insulin
- Insulin is made in beta cells in the islets of Langerhans in the pancreas which helps lower blood glucose.
- Alpha cells in the islets of Langerhans make glucagon, an antagonist to insulin that raises blood glucose.
- Insulin is primarily administered via injection into the fatty tissue under the skin.
- Rapid-acting insulin: starts to work in 15 to 30 minutes, peaks in 30 minutes to 3 hours, and lasts 3 to 5 hours.
- Regular or short-acting insulin: starts to work in 30 minutes to 1 hour, peaks in 2 to 4 hours, and lasts 4 to 12 hours.
- Intermediate-acting insulin: starts to work in 1 to 2 hours, peaks in 4 to 12 hours, and lasts 14 to 24 hours.
- Long-acting insulin: reaches the bloodstream 2 to 4 hours after injection and lasts up to 24 hours.
- Ultra long acting insulin: starts to work in 1 hour, peaks in 12 hours, and lasts 24 to 42 hours.
- Avoid injecting the medication into scars, and use a site at least 2 inches away from the navel.
- Do not administer insulin in a bruised, tender, or swollen area, and avoid lumpy, firm, or numb areas.
- Insert the needle at a 45° angle for clients who are emaciated or have little subcutaneous tissue, or at a 90° angle for clients who have adequate subcutaneous tissue.
Gastrostomy, Nasogastric, and Nasojejunal Intubation
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A gastrostomy tube (G-tube) delivers nutrition directly into the stomach and is inserted through the abdomen for clients unable to consume enough nutrition on their own.
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G-tube placement is performed by a surgeon in about 20 to 30 minutes.
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An upper endoscopy is performed to inspect the upper digestive tract for abnormalities.
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The client remains NPO for at least 8 hours before the procedure.
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Three methods are used to insert G-tubes: percutaneous endoscopic gastrostomy (PEG), laparoscopic, and open surgery.
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Percutaneous endoscopic gastrostomy (PEG) is the most common technique.
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A nasogastric (NG) tube is a thin plastic tube inserted into the nostril, down the esophagus, and into the stomach.
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It provides nutrition and medication and can remove stomach contents.
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Removal of stomach contents is facilitated by attaching the NG tube to suction.
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NG tubes are placed after a provider's prescription and are inserted by an RN or PN and placement must be verified by x-ray before its use.
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A nasoduodenal tube is inserted into the nasal passage, past the stomach, and into the duodenum.
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Nasoduodenal tubes used primarily for feedings for clients needing long-term enteral feedings for whom gastric feeding is not appropriate.
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An abdominal x-ray can to confirm placement before the tube is used.
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A nasojejunal (NJ) tube is a thin tube inserted through the nostril and stomach, ending in the jejunum.
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NJ tubes are for clients who cannot consume enough nutrition, tolerate stomach contents, or have delayed gastric emptying.
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Placing food, liquids, and medications directly into the intestines, this type of tube is placed by a provider using guided radiology, and placement is verified by x-ray.
Enteral Nutrition
- Enteral nutrition is dietary intake via a medical device such as a feeding tube prescribed for clients without adequate oral intake.
- Tube feedings can provide total sustenance or supplement the diet when cllients cannot eat safely due to swallowing impairments or dysphagia.
- Enteral nutrition has been associated with improved nutrition, lower incidence of infection, and decreased days in the hospital.
- Some contraindications include gastrointestinal bleeding, small or large bowel obstruction, and bowel ischemia.
Parenteral Nutrition
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Parenteral nutrition is dietary intake administered intravenously (IV).
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It prevents malnutrition by replacing missing nutrients for clients whose digestive system cannot absorb or tolerate adequate food.
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Parenteral nutrition, is administered into a large vein through a venous access device and the provider can customize the nutrition.
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Partial parenteral nutrition supplies part of the nutritional requirements, supplementing oral intake.
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Total parenteral nutrition gives the client their total daily nutritional requirements and may be the only option for clients without a functioning GI tract.
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A complication of total parenteral nutrition is abnormalities in glucose, including high blood glucose and insulin dose can be adjusted.
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Description
Learn about aspiration, its causes, and prevention strategies. Discover how diet modification with thickened liquids can reduce aspiration risk. Understand the importance of nursing assessments in identifying and managing aspiration risks.
