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.

Answer and Explanation

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A. Auscultating the right upper quadrant of the abdomen while injecting air into the tube is an outdated and unreliable method for confirming tube placement.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C. Auscultating the left upper quadrant of the abdomen while injecting air into the tube is another outdated and unreliable method, similar to auscultating the right upper quadrant.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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Correct Answer is ["62.5"]

Explanation

Convert hours to minutes:

4 hours 60 minutes/hour = 240 minutes

Calculate the total drops:

1000 mL 15 gtt/mL = 15000 gtt

Calculate the drops per minute:

15000 gtt / 240 minutes = 62.5 gtt/minute

A. Patient with blood pressure of 150/75 mm Hg and heart rate of 102 beats/min B. Patient with a temperature of 100.5° F who is asleep but easily roused C. Patient with respiratory rate of 10 breaths/min who is breathing deeply D. Patient with a respiratory rate of 8 breaths/min who is snoring

Correct Answer is D

Explanation

A. Blood pressure and heart rate are not indicators of opioid overdose; these values are within a normal range and do not suggest respiratory depression.
B. A temperature of 100.5°F and sleepiness are concerning but not life-threatening in isolation; the patient is easily aroused, which suggests they are not in respiratory distress.
C. A respiratory rate of 10 breaths/min is low, but if the patient is breathing deeply, they may still be compensating, and further monitoring is necessary.
D. A respiratory rate of 8 breaths/min with snoring is indicative of severe respiratory depression, a life-threatening side effect of opioid use. Immediate intervention is necessary.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is to receive 1000 mL of IV fluid over 4 hours. The drop factor is 15 gtt/mL. How many drops per minute should the IV be set to deliver? NOTE DO NOT write the unit/s of measurement Enter ONLY the number DO NOT ROUND YOUR ANSWER

Correct Answer is ["62.5"]

Explanation

The nurse is assessing a client admitted to the ICU and receiving opioid analgesic intravenously. Which patient is MOST likely to be experiencing a life-threatening opioid side effect?

Correct Answer is D

Explanation

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