The nurse places a nasogastric tube (NGT) as ordered by the physician.
When confirming placement, the nurse aspirates stomach contents and measures the gastric pH at 3. What should the nurse do next?
Secure the tube and retest the pH in one hour.
Insert the tube an additional 1-2 inches and retest the pH.
Auscultate for the "swoosh" of air.
Obtain an x-ray to confirm placement.
The Correct Answer is D
Choice A rationale
Securing the tube and retesting the pH in one hour is insufficient to confirm correct placement. While a pH of 3 suggests gastric placement (normal gastric pH is typically 1.5 to 3.5), it doesn't definitively rule out placement in the respiratory tract or intestines, as these can occasionally have acidic pH levels. Delaying definitive confirmation could lead to serious complications if the tube is misplaced.
Choice B rationale
Inserting the tube an additional 1-2 inches and retesting the pH is not a reliable method for confirming placement. Advancing the tube further without radiographic confirmation could increase the risk of trauma to the gastrointestinal tract or even pulmonary aspiration if the initial placement was incorrect. pH testing alone is not conclusive.
Choice C rationale
Auscultating for the "swoosh" of air while injecting air into the NG tube is an outdated and unreliable method for confirming placement. The sound can be misleading and may be heard even if the tube is incorrectly positioned in the esophagus or lungs. This method does not provide definitive proof of gastric placement and poses a risk of aspiration.
Choice D rationale
Obtaining an x-ray is the gold standard for confirming nasogastric tube placement. Radiographic imaging allows for direct visualization of the tube's trajectory and ensures that the distal tip is correctly positioned in the stomach or duodenum. This method provides the most accurate and reliable confirmation, minimizing the risk of complications such as aspiration or misadministration of feedings and medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1"]
Explanation
The correct answer is 1 mL.
Step 1 is: Examine the medication label to determine the concentration of epoetin. The label indicates a concentration of 30,000 units per 1 mL.
Step 2 is: Set up the calculation to find the volume needed by dividing the ordered dose by the concentration: 30,000 units ÷ (30,000 units/mL).
Step 3 is: Perform the division: 30,000 ÷ 30,000 = 1.
Step 4 is: The units cancel out, leaving the volume in milliliters: 1 mL. Final answer is 1 mL.
Correct Answer is C
Explanation
Choice A rationale
Listening for bowel sounds for only 1 minute in one area is insufficient to determine their presence or absence accurately. Bowel motility and thus bowel sounds can be intermittent, and listening for a brief period might miss infrequent sounds. A more extended auscultation is necessary to assess bowel activity adequately.
Choice B rationale
Listening for 2 minutes in each quadrant totals 8 minutes of auscultation, which is more comprehensive than 1 minute. However, bowel sounds can still be sporadic. A longer duration of listening in at least one quadrant where sounds might be present is needed before concluding they are absent.
Choice C rationale
Auscultating for bowel sounds for a total of 5 minutes (not necessarily 5 minutes in each quadrant, but listening attentively in different areas for a cumulative of 5 minutes) is the generally accepted minimum duration to confidently declare bowel sounds absent, termed "silent bowel sounds.”. This extended listening time increases the likelihood of detecting any intermittent bowel activity.
Choice D rationale
Listening for 10 minutes is even more thorough, but if no bowel sounds are heard after a continuous and attentive 5-minute auscultation, it is generally considered clinically significant for absent bowel sounds. Prolonged auscultation beyond 5 minutes is usually not necessary unless there are specific clinical indications.
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