The client had a nasogastric tube placed two days ago. Which nursing action provides the most reliable means to assess placement of a client's nasogastric tube, prior to each medication administration?

Place end of tube in water and observe for bubbling.

Using auscultation technique.

Measure pH of aspirates.

Radiographic confirmation.

Answer and Explanation

The Correct Answer is D

Radiographic confirmation. Radiographic confirmation is the most reliable method to verify the placement of nasogastric tubes, and it is considered the gold standard. The nurse should use it to confirm placement initially and periodically to ensure that the tube is in the stomach and not in the lungs or esophagus.

Option A, placing the end of the tube in water and observing for bubbling, is incorrect because it is not a reliable method, and it can cause aspiration or infection.

Option B, using the auscultation technique, is incorrect because it can lead to misinterpretation of bowel sounds, and it is not reliable.

Option C, measuring pH of aspirates, is incorrect because it is not a reliable method, and it can be affected by several factors, including medications, stress, and nutritional status.

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Correct Answer is C

Explanation

Measure abdominal girth according to a set routine. Abdominal enlargement is a common finding in clients with cirrhosis, which is a condition characterized by liver scarring and impaired liver function. Measuring abdominal girth regularly is an important nursing intervention to monitor the progression of abdominal distention and to identify potential complications such as ascites, which is an accumulation of fluid in the abdomen.

Choice A, reporting the condition to the physician immediately, may be necessary if the abdominal enlargement is sudden or accompanied by other symptoms such as severe pain or shortness of breath.

Choice B, providing the client with nonprescription laxatives, is not indicated for abdominal enlargement in clients with cirrhosis.

Choice D, asking the client about food intake, is not relevant to the assessment of abdominal enlargement in clients with cirrhosis.

A. Sensorineural. B. Mixed. C. Central. D. Conductive.

Correct Answer is D

Explanation

Conductive hearing loss occurs when there is a blockage or damage in the outer or middle ear, which prevents sound from reaching the inner ear. The accumulation of cerumen in the ear canal can cause conductive hearing loss. Sensorineural hearing loss occurs due to damage to the inner ear or auditory nerve, while mixed hearing loss is a combination of both conductive and sensorineural hearing loss. Central hearing loss occurs due to damage in the central nervous system and is not related to cerumen buildup in the ear canal.

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The client had a nasogastric tube placed two days ago. Which nursing action provides the most reliable means to assess placement of a client's nasogastric tube, prior to each medication administration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a physical examination on a client with cirrhosis, a nurse notices that the abdomen is enlarged. Which of the following interventions should the nurse consider?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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