A nurse is checking for the 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.
Auscultate for air insufflation.
Request a chest x-ray.
Check the pH level of gastric contents.
The Correct Answer is C
Choice A Reason:
Verifying the bilirubin level of the tube contents is incorrect. Measuring bilirubin levels in the tube contents is not a standard or reliable method for confirming tube placement. It's not an established or recommended technique for this purpose.
Choice B Reason:
Auscultating for air insufflation is incorrect. Auscultation for air insufflation involves injecting air into the tube and listening for bubbling sounds over the stomach area. While this method is commonly used, it can sometimes yield inconsistent or inconclusive results, especially in patients with certain conditions or situations where air movement might not be detectable.
Choice C Reason:
Request a chest x-ray is correct. Obtaining a chest x-ray is the most reliable method to confirm the placement of a feeding tube, especially when the tube is newly inserted or if there are any doubts about its location. A chest x-ray can accurately visualize the position of the tube within the gastrointestinal tract, ensuring it is in the intended location before any feedings or medications are administered.
Choice D Reason:
Checking the pH level of gastric contents is incorrect. Measuring the pH level of aspirated gastric contents can provide information about the acidity of the fluid, indicating gastric placement (pH below 5) in most cases. However, the pH can be influenced by various factors like medications, enteral feeding solutions, or certain medical conditions, making it less reliable than a chest x-ray for definitive confirmation of tube placement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
"I will rinse the contaminants from a bedpan with hot water." Is incorrect. Rinsing contaminants with hot water might not be sufficient for proper disinfection and could potentially contribute to the spread of infection. Proper disinfection methods involve using appropriate cleaning agents or disinfectants.
Choice B Reason:
"I will double-bag a client's linens each day." Is incorrect. While containing soiled linens is important, double-bagging might not necessarily be a standard practice for managing linens unless there's a specific protocol or contamination issue. It might not be directly related to infection control principles.
Choice C Reason:
"I will wear sterile gloves when bathing a client who is incontinent." Is incorrect. Wearing sterile gloves for routine bathing of an incontinent client is not typically necessary. Using clean gloves or standard precautions would generally be appropriate unless there's a specific medical procedure requiring sterile technique.
Choice D Reason:
"I will use disinfectant to clean the blood pressure cuff after use on a client." Is correct. Using a disinfectant to clean equipment, especially after use on a client, is a key infec
Correct Answer is C
Explanation
Choice A Reason:
"I'll use focused breathing to control my pain." Is incorrect. Focused breathing is a relaxation technique that can complement guided imagery, but it's not specifically imagery-based. It's more aligned with techniques like mindfulness or deep breathing exercises.
Choice B Reason:
"I'll learn to notice the sensation of muscle tension." Is incorrect. Noticing muscle tension is a part of progressive muscle relaxation, a different technique aimed at reducing physical tension, which is different from guided imagery.
Choice C Reason:
"I'll think about my grandfather's farm to reduce pain." Is correct. Guided imagery involves focusing on specific mental images or scenarios to promote relaxation, reduce stress, and manage pain. Imagining a peaceful or pleasant place, like the client's grandfather's farm, can serve as a distraction and help reduce pain perception.
Choice D Reason:
"I'll listen to my favorite music to take my mind off the pain." Is incorrect. Listening to music can be a distraction technique, but it's not specifically guided imagery. While it might help in managing pain by diverting attention, it's not rooted in imagery-focused mental visualization.
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