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
Aspirate contents from the tube and verify the pH level.
- 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 falsepositive 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","C","D","E","F"]
Explanation
The correct actions are A, B, C, D, E, and F.
- A. This is a correct action. Firmly massaging the uterine fundus can help contract the uterus and reduce bleeding by expelling clots and compressing blood vessels.
- B. This is a correct action. Providing emotional support can help calm the client and reduce anxiety, which can worsen bleeding by increasing heart rate and blood pressure.
- C. This is a correct action. Administering oxygen can help improve tissue perfusion and oxygenation, which can prevent hypoxia and shock due to blood loss.
- D. This is a correct action. Weighing the perineal pads can help estimate the amount of blood loss and monitor the effectiveness of interventions to control bleeding.
- E. This is a correct action. Inserting an indwelling urinary catheter can help empty the bladder and prevent it from displacing or compressing the uterus, which can interfere with uterine contraction and increase bleeding.
- F. This is a correct action. Administering methylergonovine can help stimulate uterine contraction and reduce bleeding by constricting blood vessels in the uterus.
Correct Answer is C
Explanation
Choice A rationale:
Tightening the tubing connections may be necessary if there is a leak in the ventilator system, but it does not address the high-pressure alarm issue. The nurse needs to address the immediate alarm situation first.
Choice B rationale:
Requesting insertion of a tracheostomy tube is not the appropriate action for a high-pressure alarm on the ventilator. Tracheostomy tube insertion is a significant procedure that is not indicated solely based on a high-pressure alarm.
Choice C rationale:
Suctioning the client's airway is the correct action for a high-pressure alarm on the ventilator. The alarm indicates an obstruction in the airway, and suctioning can help clear any secretions or blockages, allowing the client to breathe more effectively.
Choice D rationale:
Looking for a leak in the tube's cuff may be necessary if the high-pressure alarm persists after suctioning and checking connections. Identifying and repairing any leaks can prevent further issues with ventilation. However, immediate action should be taken to clear the airway first, as indicated by suctioning.
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