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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Herpes remains dormant in the body and can recur at any time, which is important information for the nurse to understand when discussing sexually transmitted infections with clients.
Gonorrhea, chlamydia, and syphilis can be treated with antibiotics, so they do not remain dormant in the body.
Correct Answer is B
Explanation
Glucose tolerance test in combination with a Growth hormone measurement. Acromegaly is a condition in which there is an excess of growth hormone (GH) production by the anterior pituitary gland, resulting in abnormal growth of bones and tissues in the body. The definitive diagnostic test for acromegaly involves a glucose tolerance test combined with a measurement of GH levels. During the test, the client will be given a dose of glucose, and the GH levels will be measured before and after the glucose is given. In acromegaly, the GH levels remain elevated even after glucose administration.
Choice A, bone radiographs, may show the enlarged bones associated with acromegaly, but it is not the definitive diagnostic test for the condition.
Choice C, growth hormone levels, is not specific enough for diagnosing acromegaly, as elevated GH levels can occur in other conditions as well.
Choice D, a serum glucose level, is not specific for acromegaly, as the glucose level may be normal in clients with the condition.
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