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

The fracture is on the diaphysis. The femur, which is the thigh bone, is made up of three parts: the head, neck, and diaphysis. The diaphysis is the long, cylindrical part of the bone between the proximal and distal ends. When reporting the location of a fracture on the femur, it is most accurate to describe the location as being on the diaphysis.

Choice A, the fracture is on the epiphyses, is incorrect because the epiphyses are the rounded ends of the bone and are not typically involved in long bone fractures.

Choice B, the fracture is on the tuberosity, is incorrect because the tuberosity is a bony prominence where muscles attach and is not typically involved in long bone fractures.

A. Obtain a glucometer reading. B. Administer fruit juice. C. Start an IV of dextrose. D. Call the physician.

Correct Answer is A

Explanation

choice A, Obtain a glucometer reading. The immediate action taken by the nurse is to obtain a glucometer reading to determine the client's blood glucose level. The client's symptoms are suggestive of hypoglycemia, a condition that can lead to coma and seizures if left untreated. Administering fruit juice or starting an IV of dextrose without first checking the client's blood glucose level can worsen the condition if the client's blood glucose is high. The physician should be notified if the client's blood glucose level is critically low or high and if the client's condition does not improve after treatment.
B. Administering fruit juice can worsen the condition if the client's blood glucose is high.
C. Starting an IV of dextrose can worsen the condition if the client's blood glucose is high.
D. Calling the physician is not the immediate action, as the client needs urgent treatment.

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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

The emergency room nurse is reporting the location of a fracture to the client's primary car. When stating the location of the fracture on the long shaft of the femur, the nurse would be most correct to state which terminology locating the fractured site?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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