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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?

A.

Insert air in the tube and listen for gurgling sounds in the epigastric area

B.

Aspirate contents from the tube and verify the pH level

C.

Review the medical record for previous x-ray verification of placement

D.

Auscultate the lungs for adventitious breath sounds

Answer and Explanation

The Correct Answer is B

Aspirate contents from the tube and verify the pH level.

  • 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 falsepositive 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.


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Related Questions

Correct Answer is C

Explanation

  • A. Incorrect. A 1-inch needle may not be long enough to reach the muscle layer in an obese client, which may result in subcutaneous injection and reduced absorption of the medication.
  • B. Incorrect. A 45° angle may not be appropriate for an IM injection, as it may cause the needle to enter at an oblique angle and miss the muscle layer or hit a bone or nerve.
  • C. Correct. The ventrogluteal site is preferred for IM injections in obese clients, as it has less subcutaneous fat and a large muscle mass that can accommodate larger volumes of medication.
  • D. Incorrect. Pinching the skin up during injection may cause the needle to enter at a shallow angle and deposit the medication in the subcutaneous tissue instead of the muscle layer.

Correct Answer is D

Explanation

A is incorrect because the client should stand with their feet together, not 1 foot apart, for the Romberg test.

B is incorrect because the client should hold their arms at their sides, not on their hips, for the Romberg test.

C is incorrect because the nurse should stand close to the client, not across the room, to prevent injury in case of a fall.

D is correct because the Romberg test involves checking the client's balance with their eyes open and then with their eyes closed.

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