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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?

A.

Insert air in the tube and listen for gurgling sounds in the epigastric area

B.

Aspirate contents from the tube and verify the pH level

C.

Review the medical record for previous x-ray verification of placement

D.

Auscultate the lungs for adventitious breath sounds

Answer and Explanation

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.


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Related Questions

Correct Answer is C

Explanation

Choice A rationale:

Limiting fluid intake to 1 liter per day can lead to dehydration and other health complications. It is important for the client to maintain adequate hydration, especially postpartum. This option is incorrect and potentially harmful.

Choice B rationale:

Manual expression of milk can help relieve engorgement without stimulating further milk production. This method allows the client to express milk as needed. However, it can be done even before engorgment occurs

Choice C rationale:

Wearing a snug-fitting bra can provide support and comfort.

Choice D rationale:

Applying moist heat to the breasts can stimulate milk production and relieve engorgement. However, in this case, the client wants to suppress lactation. Therefore, this option is not appropriate and may have the opposite effect of increasing milk production.

Correct Answer is C

Explanation

Choice A rationale:

Fidelity refers to the principle of being loyal, faithful, and keeping promises. It does not specifically relate to providing accurate information about treatment effects. In this scenario, the nurse is discussing the potential adverse effects of a treatment, which falls under the domain of providing accurate and truthful information to the client.

Choice B rationale:

Beneficence is the ethical principle of doing good and promoting the well-being of the patient. While educating the client about potential adverse effects is a form of beneficence, the specific principle demonstrated in this scenario is veracity, which is the duty to tell the truth. The nurse is being truthful about the potential side effect (lightheadedness) while clarifying that it should not affect memory.

Choice C rationale:

Veracity is the ethical principle of truth-telling. In this scenario, the nurse is demonstrating veracity by providing honest and accurate information to the client about the potential adverse effects of transcranial magnetic stimulation. By being truthful, the nurse upholds the ethical principle of veracity.

Choice D rationale:

Autonomy refers to the principle of respecting the patient's right to make decisions about their own healthcare. While respecting autonomy is important, the nurse's action in this scenario specifically pertains to providing accurate information (veracity) rather than solely focusing on the client's decision-making autonomy.

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