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Auscultating for the "swoosh" of air while injecting air into the NG tube is an outdated and unreliable method for confirming placement.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 ["0.17"]
Explanation
Step 1: The ordered dose is 17 units.
Step 2: The concentration of the insulin is 100 units/mL.
Step 3: To find the volume to administer, divide the ordered dose by the concentration: 17 units ÷ 100 units/mL = 0.17 mL.
Final answer: The nurse will administer 0.17 mL.
Correct Answer is A
Explanation
Choice A rationale
Explaining the location of food items on the plate using the clock face analogy (e.g., "your meat is at 12 o'clock, your vegetables are at 3 o'clock") provides a consistent and easily understandable spatial reference for a visually impaired patient. This method allows the patient to independently locate and access different food items, promoting autonomy during meals.
Choice B rationale
Encouraging eating one food at a time based on preference does not directly address the challenge of navigating the plate when blind. While respecting preferences is important, it doesn't provide a systematic way for the patient to know where each food item is located.
Choice C rationale
Ordering finger foods might seem helpful, but it limits the variety and nutritional balance of the patient's diet. Not all foods can be easily eaten with fingers, and this approach does not promote independence in eating a regular meal.
Choice D rationale
Feeding the patient completely removes their independence and can be disempowering. The goal is to assist the patient in maintaining as much autonomy as possible, and explaining food placement allows them to eat independently.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.