The nurse inserts a small-bore nasoduodenal tube for a patient who is undernourished.
What priority nursing action is required prior to starting the continuous tube feeding to confirm correct tube placement?
Request an x-ray before starting the feeding.
Assess for carbon dioxide using capnometry.
Auscultate over the epigastric area.
Perform pH testing of gastric fluid.
The Correct Answer is A
Choice A rationale
The gold standard for confirming the correct placement of a nasoduodenal tube is a chest or abdominal x-ray. This is a priority action because it provides a definitive visual confirmation of the tube's location, ensuring it is not misplaced in the trachea or bronchi, which could lead to fatal aspiration of the feeding.
Choice B rationale
Assessing for carbon dioxide using capnometry is a method used to detect tracheal placement of an endotracheal tube. While a positive reading indicates respiratory placement, a negative reading does not definitively confirm gastrointestinal placement of a small-bore tube. Aspiration of gastric contents and other factors can produce false negatives.
Choice C rationale
Auscultating for a rush of air over the epigastric area after injecting air is an unreliable method for confirming nasoduodenal tube placement. The sound can be misleading and does not guarantee the tube is not in the lungs, as the sounds can be transmitted from the esophagus or trachea, leading to a false sense of security.
Choice D rationale
Performing a pH test of gastric fluid can indicate placement in the stomach if the pH is acidic (typically 1-5). However, it does not confirm duodenal placement and can be unreliable if the patient is on acid-suppressing medication. A pH greater than 6 could indicate placement in the lungs or intestines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Urinary retention is a common symptom of various genitourinary conditions in older adults, such as benign prostatic hyperplasia or medication side effects. While it can occur with a UTI, it is not a specific or unique manifestation of a UTI in this population, as it is also a symptom of other conditions.
Choice B rationale
Incontinence can be a symptom of a UTI, particularly in older adults who may have weakened bladder control. However, new-onset incontinence can also be related to other issues such as weakened pelvic floor muscles, medications, or neurological conditions, making it a non-specific finding.
Choice C rationale
Confusion or a sudden change in mental status is a hallmark and often the only sign of a urinary tract infection in older adults. Due to an altered immune response and less localized inflammatory response, they may not exhibit classic symptoms like dysuria or fever, making confusion a specific and critical indicator of infection.
Choice D rationale
Low back pain can be a symptom of a urinary tract infection, particularly if the infection has ascended to the kidneys (pyelonephritis). However, low back pain is a very common complaint in older adults due to musculoskeletal issues, arthritis, and other conditions, which makes it a non-specific and unreliable indicator.
Correct Answer is A
Explanation
Choice A rationale
Dehydration leads to a decreased urine volume and an increased concentration of stone-forming salts, such as calcium, oxalate, and uric acid. When the urine is highly concentrated, these substances are more likely to crystallize and aggregate, forming renal calculi. Maintaining adequate hydration is a key preventative measure for urolithiasis.
Choice B rationale
Iron deficiency is not directly linked to an increased risk of renal calculi. Renal calculi formation is primarily related to the supersaturation of urine with minerals and salts, which is influenced by factors like diet, fluid intake, and metabolic conditions, not by iron status.
Choice C rationale
While obesity can be a risk factor for certain types of kidney stones, particularly uric acid stones, it is not as direct and universal a cause as dehydration. Dehydration is a primary and immediate risk factor for all types of renal calculi, as it directly affects urine concentration, which is the key mechanism of stone formation.
Choice D rationale
Protein in the urine, or proteinuria, is a sign of kidney damage, not a cause of renal calculi. While certain metabolic conditions can cause both proteinuria and kidney stones, the presence of protein itself does not lead to the formation of kidney stones. It is typically a symptom of underlying kidney disease.
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