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.

Answer and Explanation

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Auscultating for the "swoosh" of air while injecting air into the NG tube is an outdated and unreliable method for confirming placement.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.

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Correct Answer is C

Explanation

Choice A rationale

Breathing in and out normally does not protect the airway during nasogastric tube removal. The risk of aspiration is present as the tube is withdrawn, and normal breathing does not actively close off the trachea.

Choice B rationale

Taking a deep breath and coughing can help to clear the airway after the tube is removed but does not directly aid in preventing aspiration during the removal process itself. Coughing expels material from the lungs and throat.

Choice C rationale

Holding her breath during nasogastric tube removal helps to close the epiglottis, which covers the trachea. This action minimizes the risk of aspiration of any residual secretions or reflux that might occur as the tube is being withdrawn.

Choice D rationale

Bearing down, or performing the Valsalva maneuver, increases intra-abdominal pressure and is typically used to stimulate a bowel movement. It is not relevant to protecting the airway during nasogastric tube removal and could potentially increase the risk of reflux.

A. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened. B. Acknowledge it as benign breast enlargement, which is not unusual in men. C. Recommend that he make an appointment with his physician for a mammogram. D. Explain that this condition may be the result of hormonal changes and recommend that he see his physician.

Correct Answer is D

Explanation

Choice A rationale

While prostate enlargement is common in older men, it is not typically directly associated with bilateral gynecomastia. Gynecomastia primarily involves breast tissue enlargement due to hormonal imbalances, not glandular changes related to the prostate. Recommending prostate screening solely based on gynecomastia is not the most direct or scientifically sound approach.

Choice B rationale

Acknowledging gynecomastia as benign breast enlargement without further investigation might be premature. While some cases in older men are benign and related to aging, it can also be a symptom of underlying medical conditions or medication side effects that require evaluation. Dismissing it without investigation could miss a treatable cause.

Choice C rationale

A mammogram is a screening tool for breast cancer, which is rare in men but possible. However, gynecomastia is characterized by benign glandular tissue proliferation, distinct from the tissue changes typically associated with male breast cancer. While a physician might order one to rule out malignancy, it's not the initial recommended action based solely on the finding of bilateral gynecomastia.

Choice D rationale

Gynecomastia in men can result from various hormonal changes, including a decrease in testosterone levels relative to estrogen, or an increase in estrogen production. Certain medical conditions and medications can also disrupt hormonal balance. Recommending a physician visit to investigate potential underlying causes of hormonal changes is the most appropriate initial action to determine the etiology of the gynecomastia and guide further management.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia.Which of the following describes the nurse's best course of action?

Correct Answer is D

Explanation

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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?