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 C
Explanation
Irrigating the tube with 30 mL of sterile saline as needed. This prescription should be questioned by the nurse because it may cause trauma to the kidney or dislodge the tube. The nurse should only irrigate the tube if ordered by the health care provider and with a smaller amount of fluid.
Choice A is wrong because monitoring the urine’s color and odor is an appropriate intervention for a client with a nephrostomy tube. The urine may be bloody or cloudy initially, but it should gradually clear.
Choice B is wrong because recording the intake and output every eight hours is also an appropriate intervention for a client with a nephrostomy tube. The nurse should measure and document the amount and characteristics of urine drainage and report any changes or abnormalities.
Choice D is wrong because measuring the vital signs every four hours during the day is a reasonable prescription for a client with a nephrostomy tube. The nurse should monitor the client for signs of infection, bleeding, or obstruction.
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