Nclexpn Quiz: Enteral Feeding And Aspiration Risk

What this quiz covers

This quiz focuses on Enteral Feeding And Aspiration Risk, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexpn.

How to use this quiz

Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

Question 1

1. Document the findings and continue to monitor
2. Increase the amount of free water flushes
3. Check blood glucose and administer insulin per sliding scale
4. Stop the feeding and elevate the head of the bed while assessing respiratory status (correct answer)

Explanation: This question tests understanding of enteral feeding and aspiration risk in a client with dysphagia on nasogastric feedings. The priority framework is client safety through prevention of aspiration, responding to auditory cues. The correct answer, stopping the feeding and elevating the head of the bed while assessing respiratory status, is the best choice because it prevents further aspiration and allows lung sound evaluation. The distractors are incorrect because increasing water flushes doesn't address crackles, checking glucose is unrelated, and documenting without action delays care. The decision-making principle is to stop feedings upon hearing coughing or crackles. Elevation promotes drainage and breathing ease. A transferable strategy is to auscultate during feedings, pausing and repositioning if adventitious sounds appear.

Question 2

1. Administer the feeding as scheduled.
2. Dilute the formula with sterile water.
3. Hold the feeding and notify the registered nurse (RN). (correct answer)
4. Re-instill the residual and recheck in 4 hours.

Explanation: A gastric residual volume (GRV) of 150 mL may indicate delayed gastric emptying, which places the client at risk for aspiration. The PN's scope of practice requires reporting this significant finding to the RN. The RN will then collaborate with the healthcare provider to determine the next steps. Administering the feeding, diluting the formula, or waiting 4 hours without notifying the RN would be unsafe.

Question 3

1. Auscultating for a rushing sound over the epigastrium while injecting air.
2. Aspirating gastric contents and checking the pH. (correct answer)
3. Asking the client if they feel the tube is in the right place.
4. Measuring the external length of the tube.

Explanation: While an X-ray is the gold standard for initial placement verification, checking the pH of aspirated gastric contents is the most reliable bedside method for routine checks before each feeding. A pH of 5 or less is indicative of gastric placement. The air insufflation (whoosh test) is no longer considered reliable. Measuring the external length can help detect displacement, but it does not confirm tip placement. The client's sensation is not a reliable indicator.

Question 4

1. Presence of active bowel sounds in all four quadrants.
2. A soft, non-distended abdomen.
3. The client passing flatus.
4. Reports of abdominal cramping and vomiting. (correct answer)

Explanation: Abdominal cramping, distention, nausea, and vomiting are key signs of feeding intolerance. Active bowel sounds, a soft abdomen, and passing flatus are all indicators of normal gastrointestinal function and suggest the client is tolerating the feeding well.

Question 5

1. Fluid volume overload.
2. Hypoglycemia.
3. Dehydration. (correct answer)
4. Aspiration pneumonia.

Explanation: High-protein formulas have a high solute load, which can lead to osmotic diuresis and dehydration if the client does not receive adequate free water. The signs and symptoms of thirst, poor skin turgor, and dry mucous membranes are classic indicators of dehydration. The PN's role is to recognize these cues and report them to the RN for further action.

Question 6

1. Continuous infusion via an electronic pump.
2. Cyclic feeding administered over 12 hours.
3. Intermittent bolus feeding via a syringe. (correct answer)
4. Gravity drip feeding administered over 60 minutes.

Explanation: Bolus feedings involve administering a large volume of formula over a very short period (e.g., 15-30 minutes). This rapid instillation of volume into the stomach increases intragastric pressure and the risk of reflux and aspiration, especially in clients with delayed gastric emptying. Slower methods like continuous, cyclic, or gravity drip feedings are generally better tolerated and pose a lower aspiration risk.

Question 7

1. Administer the medication without interrupting the feeding.
2. Stop the feeding for 30 minutes, give the medication, and then restart the feeding. (correct answer)
3. Mix the medication with a small amount of formula to improve absorption.
4. Request that the provider change the medication to an intravenous form.

Explanation: To administer a medication on an empty stomach, the feeding must be held. The standard procedure is to stop the feeding for a period (e.g., 15-30 minutes) before and after medication administration to allow for proper absorption. The PN should then flush the tube, administer the medication, flush again, and then restart the pump after the appropriate waiting period. Administering it with formula would violate the 'empty stomach' order.

Question 8

1. Using a large-bore nasogastric tube.
2. Keeping the client in a supine position after feedings.
3. Administering the feeding at a slow, controlled rate. (correct answer)
4. Providing formula directly from the refrigerator.

Explanation: For a client with GERD, rapid administration of formula can increase gastric pressure and exacerbate reflux, increasing aspiration risk. Administering the feeding at a slower rate, such as with a continuous or gravity drip, is a key intervention. A large-bore tube can interfere with esophageal sphincter function. Supine positioning and cold formula would increase aspiration risk and cause discomfort.

Question 9

1. Stop the feeding infusion. (correct answer)
2. Administer oxygen via nasal cannula.
3. Lower the head of the bed.
4. Suction the client's oropharynx.

Explanation: Coughing and decreased oxygen saturation are signs of potential aspiration. The immediate priority is to stop the feeding to prevent further fluid from entering the respiratory tract. After stopping the feeding, the nurse should notify the RN, assess the client further, and implement other interventions like suctioning or applying oxygen as needed.

Question 10

1. Administer the feeding as scheduled.
2. Dilute the formula with sterile water.
3. Hold the feeding and notify the registered nurse (RN). (correct answer)
4. Re-instill the residual and recheck in 4 hours.

Explanation: A gastric residual volume (GRV) of 150 mL may indicate delayed gastric emptying, which places the client at risk for aspiration. The PN's scope of practice requires reporting this significant finding to the RN. The RN will then collaborate with the healthcare provider to determine the next steps. Administering the feeding, diluting the formula, or waiting 4 hours without notifying the RN would be unsafe.

Question 11

1. Stop the feeding infusion. (correct answer)
2. Administer oxygen via nasal cannula.
3. Lower the head of the bed.
4. Suction the client's oropharynx.

Explanation: Coughing and decreased oxygen saturation are signs of potential aspiration. The immediate priority is to stop the feeding to prevent further fluid from entering the respiratory tract. After stopping the feeding, the nurse should notify the RN, assess the client further, and implement other interventions like suctioning or applying oxygen as needed.

Question 12

1. The brand name of the enteral formula.
2. The client's appetite for oral food.
3. The time the next of kin was notified.
4. Gastric residual volume and client's tolerance of the feeding. (correct answer)

Explanation: Accurate documentation must include objective data about the procedure. This includes the amount of any gastric residual volume (GRV) checked before the feeding, the type and amount of formula given, and an objective description of how the client tolerated the procedure (e.g., 'no nausea, vomiting, or abdominal distention noted'). This information is crucial for monitoring the client and evaluating the effectiveness of the feeding plan.

Question 13

1. Fluid volume overload.
2. Hypoglycemia.
3. Dehydration. (correct answer)
4. Aspiration pneumonia.

Explanation: High-protein formulas have a high solute load, which can lead to osmotic diuresis and dehydration if the client does not receive adequate free water. The signs and symptoms of thirst, poor skin turgor, and dry mucous membranes are classic indicators of dehydration. The PN's role is to recognize these cues and report them to the RN for further action.

Question 14

1. Administer the medication without interrupting the feeding.
2. Stop the feeding for 30 minutes, give the medication, and then restart the feeding. (correct answer)
3. Mix the medication with a small amount of formula to improve absorption.
4. Request that the provider change the medication to an intravenous form.

Explanation: To administer a medication on an empty stomach, the feeding must be held. The standard procedure is to stop the feeding for a period (e.g., 15-30 minutes) before and after medication administration to allow for proper absorption. The PN should then flush the tube, administer the medication, flush again, and then restart the pump after the appropriate waiting period. Administering it with formula would violate the 'empty stomach' order.

Question 15

1. Using a large-bore nasogastric tube.
2. Keeping the client in a supine position after feedings.
3. Administering the feeding at a slow, controlled rate. (correct answer)
4. Providing formula directly from the refrigerator.

Explanation: For a client with GERD, rapid administration of formula can increase gastric pressure and exacerbate reflux, increasing aspiration risk. Administering the feeding at a slower rate, such as with a continuous or gravity drip, is a key intervention. A large-bore tube can interfere with esophageal sphincter function. Supine positioning and cold formula would increase aspiration risk and cause discomfort.

Question 16

1. Auscultating for a rushing sound over the epigastrium while injecting air.
2. Aspirating gastric contents and checking the pH. (correct answer)
3. Asking the client if they feel the tube is in the right place.
4. Measuring the external length of the tube.

Explanation: While an X-ray is the gold standard for initial placement verification, checking the pH of aspirated gastric contents is the most reliable bedside method for routine checks before each feeding. A pH of 5 or less is indicative of gastric placement. The air insufflation (whoosh test) is no longer considered reliable. Measuring the external length can help detect displacement, but it does not confirm tip placement. The client's sensation is not a reliable indicator.

Question 17

1. The external bumper is resting lightly against the skin.
2. The tube can be gently rotated 360 degrees.
3. Redness, swelling, and purulent drainage are present at the site. (correct answer)
4. A small amount of clear drainage is noted on the dressing.

Explanation: Redness, swelling, and purulent drainage are classic signs of a site infection, which must be reported to the RN and healthcare provider for further evaluation and treatment. The ability to rotate the tube, the bumper resting on the skin, and a small amount of clear or serous drainage are normal findings for a mature G-tube site.

Question 18

1. Continue the feeding at a much slower rate.
2. Lower the head of the bed to prevent fatigue.
3. Stop the feeding and turn the client to a side-lying position. (correct answer)
4. Administer a prescribed antiemetic medication.

Explanation: The immediate priorities are to prevent further vomiting and to protect the client's airway from aspiration. The nurse must first stop the feeding and then position the client on their side to allow the vomitus to drain out of their mouth. Continuing the feeding or lowering the head of the bed would increase the risk of aspiration. Administering medication is not the first priority.

Question 19

1. Mixing the crushed medication directly into the enteral formula.
2. Flushing the tube with water before and after administering the medication. (correct answer)
3. Using cold water to dissolve the medication to prevent clumping.
4. Crushing an enteric-coated tablet and dissolving it in water.

Explanation: To ensure the client receives the full dose and to maintain tube patency, the tube must be flushed with water (typically 15-30 mL) before giving the medication and flushed again after. This clears the tube of formula and ensures the medication is delivered to the stomach. Medications should not be mixed with formula due to potential incompatibilities. Enteric-coated tablets should never be crushed. Room temperature water is preferred for dissolving medications.

Question 20

1. Gastric residual volume of 40 mL.
2. A new onset of crackles auscultated in the lungs. (correct answer)
3. The client reports feeling hungry before the next feeding.
4. The skin around the client's nares is dry.

Explanation: New onset of crackles in the lungs is a significant finding that could indicate fluid in the lungs from aspiration of the feeding formula. This is a potential medical emergency that requires immediate reporting and intervention. The other findings are either normal or require routine intervention but are not urgent.