A patient has a new order for intermittent nasogastric feedings every 4 hours. The nasogastric tube is placed by the nurse. What is the most accurate method for confirming the placement of the tube before initiating the feeding?
Auscultate the right upper quadrant of the abdomen while injecting air into the tube.
Obtain radiography of the abdomen
Auscultate the left upper quadrant of the abdomen while injecting air into the tube.
Check the pH of fluid aspirated from the tube.
The Correct Answer is D
A. Auscultating the right upper quadrant of the abdomen while injecting air into the tube is an outdated and unreliable method for confirming tube placement. This technique can lead to false positives and is not recommended.
B. Obtaining radiography of the abdomen is a highly accurate method for confirming nasogastric tube placement but is not always the first-line method due to the need for imaging and exposure to radiation. However, it may be used if other methods are uncertain.
C. Auscultating the left upper quadrant of the abdomen while injecting air into the tube is another outdated and unreliable method, similar to auscultating the right upper quadrant.
D. Checking the pH of fluid aspirated from the tube is the most accurate and recommended method. Gastric fluid typically has a pH of 1.5 to 3.5, whereas respiratory or intestinal fluids have higher pH levels. Checking the pH is a simple and reliable way to confirm the placement of the nasogastric tube.
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Related Questions
Correct Answer is C
Explanation
A. Excessive fluid losses may lead to dehydration, but this is not typically a primary concern for patients with pulmonary alterations unless there is significant vomiting, diarrhea, or blood loss.
B. Hemodilution is not a common concern in patients with pulmonary alterations. Hypernatremia typically occurs with fluid loss or inadequate fluid intake, but it is not a direct concern related to pulmonary issues.
C. Fluid volume excess can lead to right-sided heart failure in patients with pulmonary alterations. If fluid accumulates, it can worsen pulmonary symptoms and increase the workload on the heart, potentially leading to right-sided heart failure.
D. Fluid retention with tachypnea is not typically a direct cause of fluid retention. While tachypnea is associated with respiratory distress, fluid retention is more closely linked to heart failure or kidney dysfunction.
Correct Answer is D
Explanation
A. Evaluating the patient's level of consciousness using the Glasgow Coma Scale is important, but it is secondary to ensuring that the airway is open and that breathing is maintained.
B. Informing the patient that the RN-FNE cannot act on the patient's behalf is unnecessary at this point; the priority is immediate medical intervention.
C. Monitoring vital signs, such as blood pressure and pulse, is crucial but secondary to addressing immediate life-threatening conditions like airway compromise.
D. Assessing the patient's airway is the priority because airway compromise is the most critical issue in emergency care. The RN-FNE must stabilize the patient's airway first before proceeding with other assessments.
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