A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, "I miss being able to go places with my friends." Which of the following is an appropriate response by the nurse?

Choice A Reason:

Verifying the bilirubin level of the tube contents is incorrect. Measuring bilirubin levels in the tube contents is not a standard or reliable method for confirming tube placement. It's not an established or recommended technique for this purpose.

Choice B Reason:

Auscultating for air insufflation is incorrect. Auscultation for air insufflation involves injecting air into the tube and listening for bubbling sounds over the stomach area. While this method is commonly used, it can sometimes yield inconsistent or inconclusive results, especially in patients with certain conditions or situations where air movement might not be detectable.

Choice C Reason:

Request a chest x-ray is correct. Obtaining a chest x-ray is the most reliable method to confirm the placement of a feeding tube, especially when the tube is newly inserted or if there are any doubts about its location. A chest x-ray can accurately visualize the position of the tube within the gastrointestinal tract, ensuring it is in the intended location before any feedings or medications are administered.

Choice D Reason:

Checking the pH level of gastric contents is incorrect. Measuring the pH level of aspirated gastric contents can provide information about the acidity of the fluid, indicating gastric placement (pH below 5) in most cases. However, the pH can be influenced by various factors like medications, enteral feeding solutions, or certain medical conditions, making it less reliable than a chest x-ray for definitive confirmation of tube placement.

Choice A Reason:

While documenting the refusal is important for accurate record-keeping and to ensure communication among the healthcare team, addressing the client's immediate concerns and attempting to resolve the issue of medication refusal should take precedence before documenting.

Choice B Reason:

Returning the medication is a procedural step but is not the immediate action needed when a client refuses medication due to adverse effects. First, it's important to address the client's concerns and discuss the potential consequences of refusal.

When a client refuses medication due to experiencing adverse effects, the initial action for the nurse to take is:

Choice C Reason:

Inform the client of the potential consequences of their refusal is correct. It's essential to engage in a conversation with the client to understand their concerns and educate them about the potential consequences of not taking their antihypertensive medication. The nurse should discuss the risks associated with untreated high blood pressure to ensure the client is informed about the importance of the prescribed medication.

Choice D Reason:

Notifying the provider is important, but it is generally done after the nurse has attempted to address the client’s concerns and informed them of the consequences. The provider should be informed if the refusal persists or if the nurse believes the situation requires further medical intervention.