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 C
Explanation
Choice A Reason:
"The sides of the sling are for the client to hold on to." Is inaccurate. The sides of the sling in a mechanical lift are typically designed for the lift's attachment points, not for the client to hold on to. Clients usually need to remain relaxed and may not be able to hold on during the transfer.
Choice B Reason:
"The lower end of the sling goes below the client's calves." Is inaccurate. While it's important to position the sling correctly, stating that the lower end goes below the client's calves might not be universally accurate. The placement of the sling would depend on the type of lift and the specific needs of the client. It's crucial to follow manufacturer instructions and individualized care plans for sling placement.
Choice C Reason:
"This type of device is used for a client who cannot assist." Is accurate. This statement correctly identifies the primary purpose of a mechanical lift, which is to assist individuals who are unable to bear weight or assist with movement due to physical limitations. The mechanical lift helps transfer individuals safely without relying on their own strength or ability to assist in the movement.
Choice D Reason:
"The device requires the client to use upper body strength." Is inaccurate. This statement is incorrect. The purpose of a mechanical lift is to assist clients who cannot use their own strength, especially those who cannot bear weight or assist with movement. It is the machine that aids in lifting and transferring the individual, not the client's strength.
Correct Answer is D
Explanation
Choice A Reason:
Turn the client every 4 hr. is incorrect. While repositioning is crucial for preventing pressure ulcers in immobile patients, turning the client every 4 hours might not directly address the issue of fecal incontinence or skin protection in the perineal area.
Choice B Reason:
Cleanse the perineal area with povidone-iodine solution is incorrect. Povidone-iodine solution might be too harsh for routine perineal care and can potentially irritate the skin. A gentler cleansing solution is typically recommended to avoid further skin irritation.
Choice C Reason:
Apply cornstarch powder to the perineal area is incorrect. Cornstarch powder might exacerbate moisture-related skin issues in the perineal area by creating a damp environment, potentially leading to skin maceration and worsening skin problems. It's not typically recommended for use in managing fecal incontinence.
Choice D Reason:
Place a moisture barrier ointment over the perineal area is correct. Using a moisture barrier ointment can help protect the skin from irritation and breakdown caused by prolonged exposure to fecal matter, reducing the risk of skin breakdown and discomfort.
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