A nurse is about to administer an intermittent enteral feeding to a client who has an NG tube in place. Besides obtaining an x-ray, which of the following methods should the nurse use to verify the placement?
Inject air and listen for bubbling.
Test the pH of the gastric aspirate.
Measure the gastric residual.
Add food coloring to the formula.
The Correct Answer is B
This is done by aspirating a small amount of stomach contents and testing the pH using pH paper or a pH indicator strip. The pH of stomach contents is typically acidic (pH less than 5), indicating proper placement in the stomach.
Injecting air and listening for bubbling is not a reliable method to verify tube placement, as it can lead to complications such as pneumothorax.
Measuring gastric residual is done to assess the amount of gastric contents remaining in the stomach, but it does not confirm tube placement.
Adding food coloring to the formula is not a standard practice and does not provide reliable confirmation of tube placement.
X-ray is the gold standard method to confirm tube placement but is not typically done before every intermittent feeding unless there are concerns about tube placement
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This situation involves a medication error that could potentially harm the client, and it should be reported through an incident report.
The following examples may not require an incident report:
A nurse discovers that a client's family member has administered a PCA dose. PCA (Patient-Controlled Analgesia) is a method of pain management that allows the client to self-administer pain medication within predetermined limits. If a family member administers the PCA dose without proper authorization or understanding, it is a safety concern that should be reported.
A nurse observes a client vomiting after receiving an oral pain medication. While this situation should be assessed and managed appropriately, it does not necessarily warrant an incident report unless there are additional factors or complications involved.
A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. This situation may raise concerns regarding proper restraint removal techniques or potential safety issues, but it does not inherently indicate an immediate need for an incident report. However, if the nurse's actions were contrary to policy or posed a risk to the client's safety, it should be reported.
Correct Answer is C
Explanation
This response acknowledges the client's request and demonstrates the nurse's willingness to accommodate her preferences. By offering to request a female nurse, the nurse shows respect for the client's autonomy and strives to meet her comfort and emotional needs.
The nurse should communicate this request to the appropriate individuals involved in the assignment process, such as the nurse manager or charge nurse, to ensure that the client's preferences are considered and addressed to the best of their ability.
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