A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take?
Insert air in the tube and listen for gurgling sounds in the epigastric area.
Aspirate contents from the tube and verify the pH level.
Review the medical record for previous x-ray verification of placement.
Auscultate the lungs for adventitious breath sounds.
The Correct Answer is B
A. This is an incorrect action. Inserting air in the tube and listening for gurgling sounds in the epigastric area is not a reliable method to confirm NG tube placement, as it can produce false-positive results due to air entering the stomach or intestines.
B. This is a correct action. Aspirating contents from the tube and verifying the pH level is a valid method to confirm NG tube placement, as gastric contents typically have a pH of less than 5.5, while intestinal or respiratory contents have a higher pH.
C. This is an incorrect action. Reviewing the medical record for previous x-ray verification of placement is not sufficient to confirm NG tube placement, as the tube can migrate or become dislodged after insertion. X-ray verification should be done initially and whenever there is doubt about the tube's position.
D. This is an incorrect action. Auscultating the lungs for adventitious breath sounds is not a specific method to confirm NG tube placement, as it can indicate other conditions such as pneumonia or pulmonary edema. It can also miss signs of respiratory complications due to NG tube misplacement, such as pneumothorax or bronchial obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Goal – oriented is the correct answer. Obsessive-compulsive personality disorder (OCPD) is a personality disorder characterized by a pattern of preoccupation with orderliness, perfectionism, and control. Individuals with OCPD tend to be highly organized, detail-oriented, and focused on achieving their goals. They often set strict standards for themselves and others and are driven by a strong need for perfection in all aspects of their lives.
Choice B reason
Provocative behaviour is not a characteristic commonly associated with obsessive-compulsive personality disorder (OCPD). In fact, individuals with OCPD tend to be more reserved, cautious, and serious in their interactions with others.
Choice C reason:
Lack of empathy While individuals with OCPD may struggle with interpersonal relationships due to their rigid standards and expectations, they typically do not lack empathy. They might find it challenging to understand and relate to emotions or perspectives that do not align with their own, but this is different from a complete lack of empathy, which is more commonly seen in certain other personality disorders.
Choice D reason.
Lability refers to emotional instability or rapid and extreme shifts in emotions. This is not a typical feature of obsessive-compulsive personality disorder (OCPD). Individuals with OCPD tend to be emotionally restrained and might have difficulty expressing emotions, rather than experiencing emotional lability.
Correct Answer is C
No explanation
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