A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take?
Insert air in the tube and listen for gurgling sounds in the epigastric area.
Aspirate contents from the tube and verify the pH level.
Review the medical record for previous x-ray verification of placement.
Auscultate the lungs for adventitious breath sounds.
The Correct Answer is B
A. This is an incorrect action. Inserting air in the tube and listening for gurgling sounds in the epigastric area is not a reliable method to confirm NG tube placement, as it can produce false-positive results due to air entering the stomach or intestines.
B. This is a correct action. Aspirating contents from the tube and verifying the pH level is a valid method to confirm NG tube placement, as gastric contents typically have a pH of less than 5.5, while intestinal or respiratory contents have a higher pH.
C. This is an incorrect action. Reviewing the medical record for previous x-ray verification of placement is not sufficient to confirm NG tube placement, as the tube can migrate or become dislodged after insertion. X-ray verification should be done initially and whenever there is doubt about the tube's position.
D. This is an incorrect action. Auscultating the lungs for adventitious breath sounds is not a specific method to confirm NG tube placement, as it can indicate other conditions such as pneumonia or pulmonary edema. It can also miss signs of respiratory complications due to NG tube misplacement, such as pneumothorax or bronchial obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
A: Correct. Broccoli is a vegetable that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.
B: Correct. Yogurt is a dairy product that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.
C: Incorrect. Pepperoni pizza contains pepperoni, cheese, and tomato sauce, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.
D: Incorrect. Cream cheese is a dairy product that contains tyramine, which can interact with phenelzine and cause a hypertensive crisis.
E: Incorrect. Bologna sandwich contains bologna, bread, and mayonnaise, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.
Correct Answer is B
Explanation
A. Adjust the crutches for comfort as needed. This is incorrect because the crutches should be adjusted to fit the client's height and arm length, and should not be changed without proper guidance.
B. Use a three-point gait. This is correct because this gait allows the client to avoid putting weight on the affected leg and maintain balance and stability.
C. Wear leather-soled shoes. This is incorrect because leather-soled shoes can be slippery and increase the risk of falls and injuries.
D. Advance the affected leg first when walking upstairs. This is incorrect because the client should advance the unaffected leg first when walking upstairs, and the affected leg first when walking downstairs.
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