A nurse is preparing to administer enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify the correct placement of the NG tube?

Check the pH of the gastric aspirate.

Observe the color of the gastric aspirate after adding blue dye to the formula.

Auscultate over the epigastrium.

Measure the length of the inserted NG tube.

Answer and Explanation

The Correct Answer is A

A: Correct. Checking the pH of the gastric aspirate is the most reliable method to verify the correct placement of the NG tube. Gastric aspirate typically has an acidic pH (pH < 5), indicating that the tube is in the stomach.
B: Observing the color of the gastric aspirate after adding blue dye to the formula is not a standard or recommended method for verifying NG tube placement.
C: Auscultating over the epigastrium may help to identify the presence of air in the stomach, but it does not confirm that the NG tube is correctly placed in the stomach or the intestines.
D: Measuring the length of the inserted NG tube can help determine the distance from the nose to the stomach, but it does not ensure correct placement in the stomach.

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Correct Answer is B

Explanation

A. Heart rate 62/min: A heart rate of 62 beats per minute is within the normal range for many adults and may not require immediate reporting unless it is a significant change from the client's baseline.
B. Urine output of 200 mL per 8 hr: Correct. A urine output of 200 mL in 8 hours is considered low and may indicate inadequate kidney perfusion or function. It should be reported to the provider as it could be a sign of renal impairment or dehydration.
C. Pulse oximetry 95% on room air: A pulse oximetry reading of 95% on room air is within the normal range for oxygen saturation in most healthy individuals. It does not require immediate reporting unless the client has a specific condition or baseline that warrants concern.
D. BP 112/76 mm Hg: Blood pressure of 112/76 mm Hg is within the normal range for many adults and may not require immediate reporting unless there are specific concerns related to the client's medical history or condition.

A. Stand facing the center of the bed at the client's side. B. Place feet apart with the foot nearest the head of the client's bed in front of the other foot C. Keep knees and hips straight while bending at the waist toward the client D. Encourage the client to keep their legs straight and remain still.

Correct Answer is B

Explanation

A: Standing facing the center of the bed at the client's side is not the most stable position for moving a client, as it does not provide a wide base of support.
B: Placing feet apart with one foot in front of the other provides a wide base of support and allows the nurse to use their body weight to assist in the movement, making this the correct action.
C: Keeping knees and hips straight while bending at the waist toward the client can lead to back strain and does not utilize the stronger leg muscles, making it an incorrect action.
D: Encouraging the client to keep their legs straight and remain still may be helpful, but it does not directly involve the nurse's actions in moving the client, so it is not the correct answer to this question.

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A nurse is preparing to administer enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify the correct placement of the NG tube?

Nursing Test Bank

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