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 C
Explanation
Choice A rationale:
Peer pressure (Choice A) is an external stressor, as it involves the influence of others on an individual's thoughts or actions. It originates from outside the individual and is not directly related to an internal psychological response.
Choice B rationale:
Death of a family member (Choice B) is an external stressor, as it is an event that occurs externally to the individual. While it can cause significant emotional distress, it is not considered an internal stressor.
Choice C rationale:
Fear of medical test results (Choice C) is the correct answer as an internal stressor. Internal stressors are psychological or emotional factors that originate within the individual and contribute to stress. Fear of medical test results is a personal worry that can lead to anxiety and emotional turmoil.
Choice D rationale:
Job transfer to another city (Choice D) is an external stressor, as it involves a change in the individual's external environment. It is not an internal psychological factor causing stress.
Correct Answer is C
Explanation
The correct answer is choice c. List of community resources.
Choice A rationale:
Emergency contact information is typically found in the patient’s admission records or demographic section, not in the discharge summary.
Choice B rationale:
Intake and output summary is part of the daily nursing notes or fluid balance chart, not usually included in the discharge summary.
Choice C rationale:
The discharge summary often includes a list of community resources to support the patient after discharge, such as contact information for follow-up care, support groups, or home health services.
Choice D rationale:
Basic demographic data is recorded in the patient’s initial admission records and is not typically repeated in the discharge summary.
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