A nurse is inserting an NG tube for a client who has a new prescription for enteral feedings. Which of the following actions should the nurse take to verify the placement of the client's tube? (Select all that apply.).
Measure the amount of aspirate in the NG tube.
Flush the tube with 50 mL of tap water.
Examine the color of aspirated secretions.
Measure the pH of the client's aspirate.
Obtain an x-ray of the client's chest and abdomen.
Correct Answer : A,C,D,E
Choice A rationale:
Measuring the amount of aspirate in the NG tube is one way to verify the placement of the tube. Aspirate should be tested for color, pH, and other characteristics to ensure proper positioning.
Choice B rationale:
Flushing the tube with tap water doesn't directly verify tube placement. This action might inadvertently introduce air into the tube, potentially leading to inaccurate assessment results.
Choice C rationale:
Examining the color of aspirated secretions is an essential step in verifying tube placement. Different colors of aspirate can indicate different anatomical locations, helping to ensure the tube is properly positioned.
Choice D rationale:
Measuring the pH of the client's aspirate is another important method to verify NG tube placement. Gastric aspirate tends to be acidic, while respiratory aspirate is usually more alkaline.
Choice E rationale:
Obtaining an x-ray of the client's chest and abdomen is a definitive method for confirming NG tube placement. It provides direct visualization of the tube's location and ensures accuracy.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Lying down while practicing pursed-lip breathing is not the correct instruction. Pursed-lip breathing is usually performed in a sitting or standing position. Lying down can restrict lung expansion and may not effectively support the purpose of this breathing technique, which is to improve airway pressure and reduce air trapping.
Choice B rationale:
"Exhale slowly through your mouth" is the correct instruction for pursed-lip breathing. This technique involves inhaling through the nose for a count of two and exhaling slowly and steadily through pursed lips for a count of four. The goal is to promote better exhalation, prevent airway collapse, and improve oxygen exchange. The rationale behind this choice is grounded in the mechanics of pursed-lip breathing, which helps create backpressure in the airways, maintaining them open and aiding in proper exhalation.
Choice C rationale:
Inhaling through pursed lips contradicts the proper sequence of pursed-lip breathing. The technique involves inhaling through the nose and exhaling through pursed lips. Inhaling through pursed lips would not provide the intended benefits of the technique.
Choice D rationale:
"Puff your cheeks when exhaling" is not the correct instruction. Puffing the cheeks during exhalation does not contribute to the effectiveness of pursed-lip breathing. This action could potentially impede proper exhalation and defeat the purpose of the technique, which is to control airflow and improve breathing efficiency.
Correct Answer is B
Explanation
Choice A rationale:
Using the cane to support body weight is not the correct technique. The purpose of a cane is to provide balance and support, not to bear the entire body weight. Placing the entire body weight on the cane can lead to instability and falls.
Choice B rationale:
Placing the cane next to the unaffected leg (right leg in this case) is the correct technique. This positioning provides additional support and stability on the side opposite to the affected leg. This helps in maintaining balance and reducing the risk of falling.
Choice C rationale:
The type of cane is not as relevant as using it correctly. The material of the cane doesn't impact the client's understanding of how to use it safely. While using a wooden cane might be acceptable, the material itself is not an indication of the client's understanding of safe cane use.
Choice D rationale:
Moving the right leg forward first is not the correct technique for using a cane. The correct foot to move forward first is the affected leg, in this case, the left leg. This allows the client to maintain a stable base of support while moving.
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