Which technique is most reliable to confirm correct placement of a nasogastric tube prior to initiating tube feedings?
Fluoroscopy to identify location.
Aspirate contents and measure the pH.
Inject air and listen for gurgling sounds.
Observe for bubbles after placing the end of the tube in a cup of water.
The Correct Answer is B
This is because the pH of gastric contents is acidic (less than 5.5) and can indicate that the tube is in the stomach. This method is predictive of the correct placement of a nasogastric tube.
Choice A is wrong because fluoroscopy is not the most reliable method to confirm the correct placement of a nasogastric tube. It is an imaging technique that uses X-rays to show the movement of the tube, but it is not always available or feasible.
Choice C is wrong because injecting air and listening for gurgling sounds is not a reliable method to confirm the correct placement of a nasogastric tube. It can cause false-positive results and does not differentiate between the stomach and the respiratory tract.
Choice D is wrong because observing for bubbles after placing the end of the tube in a cup of water is not a reliable method to confirm the correct placement of a nasogastric tube. It can also cause false-positive results and does not differentiate between the stomach and the respiratory tract.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because the recovery position helps maintain the airway and prevent aspiration, and loosening the necktie prevents breathing restriction.
The other choices are wrong because:
Choice A is wrong because placing a stick or any object in the person’s mouth can cause injury to the teeth, gums, tongue or jaw and obstruct the airway. The person cannot swallow or bite their tongue during a seizure.
Choice B is wrong because recording the time of the seizure is not the first priority. The first priority is to ensure the safety and comfort of the person.
Choice C is wrong because restraining the limbs can cause injury or fracture, increase agitation and prolong the seizure. The nurse should protect the person from injury by moving furniture away and padding the head.
Normal ranges for seizure duration are usually less than 5 minutes for generalized tonic-clonic seizures and less than 15 seconds for absence seizures. If the seizure lasts longer than 5 minutes, or if the person has repeated seizures without regaining consciousness, it is considered a medical emergency and requires immediate treatment.
Correct Answer is ["B"]
Explanation
Place the call bell in reach and respond promptly when activated.
This is a safety measure that allows the client to communicate their needs and request assistance when needed. The nurse should also check the drain for patency, observe for bright red bloody drainage, and maintain an aseptic technique when emptying the drain.
Choice A is wrong because advising the client to stay in bed and only get up with assistance may limit their mobility and increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumonia.
The client should be encouraged to ambulate as soon as possible after surgery, with appropriate assistance and precautions.
Choice C is wrong because maintaining the bed at working height for convenience when doing post-op vital signs may increase the risk of falls or injury if the client tries to get out of bed without assistance.
The bed should be lowered to a safe position and locked when not in use.
Choice D is wrong because keeping the lights off to encourage the client to rest and recuperate may impair the client’s vision and orientation, and increase the risk of falls or injury if they try to get out of bed without assistance.
The client should have adequate lighting in their room and be oriented to their surroundings.
Choice E is wrong because attaching the drain to wall suction and keeping the tubing pinned to the client’s gown may interfere with the function of the drain and cause tension or kinking of the tubing. The drain should be attached to gravity drainage and secured loosely to prevent accidental dislodgment.
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