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1. The nurses are discussing feeding tube migration and prevention. Which of the following statements indicates correct understanding? a) As long as the external portion of a feeding tube is taped in place, the tube will be unable to migrate out of position. *b) A feeding tube can enter the airway without causing obvious respiratory symptoms. c) The nurse should have the patient deep breathe and cough and suction the patient frequently. d) The nurse should keep the head of the bed flat to reduce the risk of tube migration. Feedback: Absence of signs and symptoms does not ensure nonrespiratory placement, especially in patients with decreased level of consciousness or altered cough and gag reflex. The nurse is responsible for ensuring that the tube has remained in the intended position before administering formula or medications through the tube. Coughing and frequent suctioning may increase the risk of feeding tube migration. A tube's distal tip can migrate upward or downward from its original correct position, even when the external portion of the tube is taped in place. The nurse should keep the head of the bed elevated 30 degrees at all times to reduce the risk of aspiration. 2. If the nurse suspects the NG feeding tube has migrated, the nurse should: a) Instill 10 mL of water into the feeding tube, reinsert the stylet, and reposition the tube. *b) Stop any enteral feedings and obtain an order for a chest x-ray to determine placement. c) Irrigate the tube with tap water. d) Reposition the patient from side to side. Feedback: If the nurse observes signs of respiratory impairment, the feeding tube may have migrated from the stomach to the airway or if the nurse obtains a larger amount of gastric residual, the tube may have migrated from the intestine to the stomach. The nurse should stop any enteral feedings, notify the physician and prepare to obtain a chest x-ray as ordered. A stylet should never be reinserted in a patient as this can cause perforation of the tube and injure the patient. Irrigating the tube with water would be appropriate if the tube were clogged. Turning the patient from side to side may help in obtaining aspirate. 3. The nurse suspects the patient’s feeding tube has migrated. Which of the following would indicate the greatest risk related to tube migration? *a) Dyspnea and decreased oxygen saturation b) Pain and gastric aspirate hemoccult positive c) Absence of bowel sounds d) Inability to flush the feeding tube Feedback: The risk for aspiration of regurgitated gastric contents into the respiratory tract is increased when the tip of an NI tube accidentally dislocates upward into the stomach or when the tip of either an NG or NI tube dislocates upward into the esophagus. When a tube migrates to the lung, complications such as aspiration, pneumonia, pneumothorax, and peritonitis can develop if feedings are subsequently administered. Pain and gastric aspirate hemoccult positive would be symptoms indicating perforation and subsequent bleeding. The absence of bowel sounds is indicative of paralytic ileus. The inability to flush the feeding tube is indicative of clogging of the tube. 4. You observe a confused patient pulling at her NG feeding tube. As you retape the tube to the bridge of the patient's nose, you notice that the mark on the tube has moved away from the naris. What action should you take? *a) Advance the tube until the mark is even with the naris and verify correct tube placement. b) Secure the tape on the patient's nose well with the tube in the current location. c) Remove the tube. d) Restrain the patient's hands before leaving the room. e) Pull back on the tube. Feedback: An increased external length of tube may indicate that the distal tip is incorrectly positioned. Using the tube in its current location could place the patient at greater risk for aspiration. You need to advance the tube until the mark reaches the patient's naris and then verify correct tube placement. It is unnecessary to remove the tube unless you are unable to advance the tube the desired length. Pulling back on the tube will only increase the external length of the tube, thus preventing the tube from being inserted the desired depth. 5. Identify signs and symptoms of accidental respiratory migration of a feeding tube. *a) Coughing *b) Choking *c) Cyanosis d) Sore throat e) Distention Feedback: Signs of respiratory distress such as paroxysms of coughing, choking, or persistent gagging; cyanosis; or change in respiratory patterns (e.g., increase in rate) are symptomatic of accidental feeding tube migration into the airway. A sore throat may occur because of irritation by the feeding tube. Distention of the abdomen is not a symptom of accidental respiratory migration of a feeding tube. 6. Identify the appropriate times to verify enteral tube placement by pH testing. *a) Before each intermittent feeding *b) At least once every 6 hours during continuous feedings *c) Before administration of medications through the tube d) After administration of medications through the feeding tube Feedback: Verification of correct tube placement is performed before each intermittent feeding, at least once every 6 hours when continuous feedings are given, and before medications are administered through the tube. The nurse should wait at least 1 hour after medication administration before aspirating gastric contents. Premature aspiration of gastric fluid will remove medication, reducing the dose delivered to the patient. Medication may also interfere with pH testing. 7. Which of the following, if exhibited by the patient, may increase the risk for spontaneous enteral tube dislocation? (Select all that apply.) a) Nausea b) Ambulation *c) Retching *d) Vomiting *e) Frequent nasotracheal suctioning *f) Severe bouts of coughing g) H2 antagonists Feedback: Conditions that increase the risk of spontaneous tube dislocation from the intended position include retching/vomiting, nasotracheal suctioning, and severe bouts of coughing. Nausea, ambulation, and H2 antagonists are not risk factors for spontaneous dislocation of an enteral feeding tube. 8. Instructions: Match the pH test result to the likely source. [a] 1) Patient with continuous tube feeding [b] 2) Stomach of fasting patient [c] 3) Pleural fluid from tracheobronchial tree [c] 4) Intestine of fasting patient a) 5 or higher b) 1 to 4 c) Greater than 6 Feedback: Gastric fluid from a patient who has fasted for at least 4 hours usually has a pH range of 1 to 4. Fluid from an NI tube of a fasting patient usually has a pH greater than 6. A patient with continuous tube feeding may have a pH of 5 or higher. The pH of pleural fluid from the tracheobronchial tree is generally greater than 6. 9. Sequence the procedure for verifying feeding tube placement. 1) Perform hand hygiene. Apply clean gloves. Draw up 30 mL of air into syringe, then attach to end of feeding tube. Flush tube with 30 mL of air.2) Draw back on syringe and obtain 5 to 10 mL of gastric aspirate. Observe appearance of aspirate. 3)_Measure pH of aspirate. Compare the color of the strip with the color on the chart provided by the manufacturer. 4) Discard used supplies, remove gloves and discard, and perform hand hygiene. Feedback: Perform hand hygiene to reduce transmission of microorganisms. Apply clean gloves to provide protection from possible exposure to body fluids. Draw up and instill 30 mL of air. The burst of air aids in aspirating fluid more easily. Draw back on syringe, obtaining 5 to 10 mL of aspirate. Observe appearance because color may provide some indication of tube location. Gently mix aspirate. Mixing ensures equal distribution of contents for testing. Measure pH by dipping the pH strip into the fluid and comparing the color of the strip with the color chart provided by the manufacturer. The pH reading will aid in verifying tube location. Discard used supplies and gloves, and perform hand hygiene to reduce transmission of microorganisms. 10. The nurse aspirates stomach contents from a newly inserted feeding tube. The nurse is aware the patient has been on the proton-pump inhibitor omeprazole (Pepcid). The pH strip reads “3.” Where should the nurse expect the x-ray to determine placement of the feeding tube? a) In the lungs b) In the esophagus *c) In the stomach d) In the small intestine Feedback: Gastric pH should measure 1-4; the proton pump inhibitor would only increase the pH reading, making stomach contents more alkaline.
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