A nurse is checking for proper placement of a feeding tube.
Which of the following methods is the most reliable for verification of tube placement?
Verify the bilirubin level of the tube contents.
Check the pH level of gastric contents.
Auscultate for air insufflation.
Request a chest x-ray.
The Correct Answer is D
Choice A rationale
Verifying the bilirubin level of the tube contents is not a standard or reliable method for checking the placement of a feeding tube. Bilirubin is a bile pigment found in the liver and bile ducts, and its levels are not indicative of tube placement in the gastrointestinal tract.
Choice B rationale
Checking the pH level of gastric contents can help determine if the tube is in the stomach, but it is not the most reliable method. Gastric pH is typically acidic (1.5-3.5), but the pH can vary, and this method does not rule out respiratory placement or other incorrect placements.
Choice C rationale
Auscultating for air insufflation involves listening for the sound of air injected through the tube into the stomach. However, this method is not reliable as it does not confirm the exact location of the tube and can give false positives if the tube is in the esophagus or respiratory tract.
Choice D rationale
Requesting a chest x-ray is the most reliable method for verifying feeding tube placement. It provides a clear visual confirmation of the tube's location, ensuring it is correctly positioned in the stomach or small intestine and not in the respiratory tract or other incorrect locations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Encouraging a partner to eat three large meals each day may not be appropriate in end-of-life care. Clients often have reduced appetite, and small, frequent meals are usually recommended to avoid overwhelming them.
Choice B rationale
Opioids are commonly used in end-of-life care to manage pain and distress. Even if respiratory distress occurs, opioids are not typically restricted, but rather adjusted to balance pain relief and respiratory function.
Choice C rationale
Using an electric blanket can pose safety risks, including burns or electrical hazards, especially if the client is unable to communicate discomfort. Instead, alternative methods such as warm blankets are safer.
Choice D rationale
Assuming the partner can hear even if they do not respond is important. Hearing is believed to be one of the last senses to fade, and speaking to the client can provide comfort and connection.
Correct Answer is A
Explanation
Choice A rationale
Declining estrogen levels during perimenopause can indeed cause headaches. Estrogen influences neurotransmitters like serotonin, and its decline can lead to vasodilation, contributing to headaches.
Choice B rationale
Papanicolaou tests should continue even after menopause. Cervical cancer risk persists, and regular screening remains essential for early detection.
Choice C rationale
Perimenopause involves irregular periods. It's common for menstrual cycles to become erratic before they eventually cease at menopause.
Choice D rationale
The best time for a breast self-examination is after menstruation ends, when breasts are less tender and swollen. Doing it on the first day of the period is not recommended.
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