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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C.
Choice A reason: Walking on the client’s right side is incorrect because the nurse should walk on the client’s left side. This is the weaker side and the side where support is most needed.
Choice B reason: Instructing the client to look down at their feet when ambulating is incorrect because the client should be instructed to look straight ahead, not down at their feet, to maintain balance and prevent falls.
Choice C reason: Have the client sit on the side of the bed for at least 60 seconds before ambulating. This allows the nurse to assess the client’s tolerance and readiness for ambulation, and it helps prevent dizziness or fainting due to orthostatic hypotension.
Choice D reason: Placing the gait belt securely around the client’s lower chest is incorrect because the gait belt should be placed around the client’s waist, not the lower chest. This provides a secure grip for the nurse and allows for safer ambulation.
Correct Answer is A
Explanation
The correct answer is choice A. 30° lateral.
Choice A rationale:
The 30° lateral position is recommended to reduce pressure on the client’s bony prominences. This position helps distribute the client’s weight more evenly and reduces the risk of pressure injury formation.
Choice B rationale:
The lateral semi-prone recumbent position may not be as effective in reducing pressure on bony prominences as the 30° lateral position. It could potentially increase pressure on certain areas, depending on the client’s body shape and condition.
Choice C rationale:
The supine position can increase pressure on the sacrum and heels, which are common sites for pressure injuries. Therefore, it is not the best position for a client at risk for pressure injury formation.
Choice D rationale:
The 45° supported Fowler’s position can increase pressure on the sacrum and ischial tuberosities, another common site for pressure injuries. Therefore, it is not the most effective position for reducing pressure on bony prominences for a client at risk for pressure injury formation.
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