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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Turning the client on their back during seizures is not recommended as it can obstruct the airway and increase the risk of injury. Positioning on the side is safer to maintain an open airway.

Choice B rationale

Gently restraining the client during seizures can cause injury and is not advisable. It is important to protect the client from harm by clearing the area around them instead.

Choice C rationale

Loosening the client’s clothing during seizures can help ensure they are not restricted and can breathe comfortably. It also reduces the risk of injury from tight or constrictive clothing.

Choice D rationale

Inserting a washcloth or any object into the client’s mouth during seizures is dangerous and can cause choking or damage to the teeth and mouth. The focus should be on ensuring safety without putting objects in the mouth.

A. Suggest that the family member contact a grief counselor. B. Describe a personal experience with the death of a family member. C. Include the family member in providing care for the client. D. Ask if they have had prior experience with the death of a family member.

Correct Answer is C

Explanation

Choice A rationale

Suggesting that the family member contact a grief counselor may be helpful, but it does not address their immediate need to help. Involving the family member in care can provide emotional support and a sense of purpose.

Choice B rationale

Describing a personal experience with the death of a family member may offer empathy but can shift the focus away from the client's needs. It is essential to keep the conversation centered on the family member's desire to help.

Choice C rationale

Including the family member in providing care for the client is an appropriate action. It allows them to participate actively, provides emotional support, and can be comforting for both the client and the family member.

Choice D rationale

Asking if the family member has had prior experience with the death of a family member may be relevant but does not directly address their desire to help. It is more effective to involve them in the care process immediately. .

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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?

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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?