A nurse is caring for a client who requires an NG tube. After inserting the tube, the nurse tests the pH of the client's aspirate. Which of the following pH levels should the nurse identify as an indication of correct placement of the tube?

8.0

6.0

7.0

4.0

Answer and Explanation

The Correct Answer is D

A. 8.0: An aspirate pH of 8.0 would indicate an alkaline substance. This would not be typical of stomach contents, which are acidic. An alkaline pH might suggest placement in the intestines or respiratory tract.

B. 6.0: While this is less alkaline than 8.0, it is still not within the typical range for stomach contents. Stomach aspirate is generally more acidic.

C. 7.0: A pH of 7.0 is neutral. Stomach contents are typically more acidic, so a neutral pH would not be consistent with correct NG tube placement in the stomach.

D. 4.0: This is within the acidic range and is consistent with the pH of stomach contents. It would be considered an indication of correct NG tube placement in the stomach.

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Correct Answer is D

Explanation

A. Diminished reflexes:
Explanation: Diminished reflexes are not typically associated with hypoglycemia. Instead, hypoglycemia may cause hyperactive reflexes or tremors.

B. Rapid respirations:
Explanation: Rapid respirations are not a common manifestation of hypoglycemia. In hypoglycemia, the body might respond with shallow, rapid breathing or hyperventilation.

C. Acetone breath:
Explanation: Acetone breath, often described as fruity or sweet, is associated with diabetic ketoacidosis (DKA), which is a complication of hyperglycemia rather than hypoglycemia.

D. Headache:
Explanation: Headache is a common manifestation of hypoglycemia. It can occur as a result of decreased glucose levels affecting the brain.

A. Check the gastric residual every 8 hr. B. Change the feeding bag every 24 hr. C. Flush the tube with sterile sodium chloride solution every 2 hr. D. Position the head of the client's bed at 15.

Correct Answer is ["B"]

Explanation

Correct answer: B

A. Check the gastric residual every 8 hr:
Explanation:It is generally recommended to check gastric residuals more frequently than every 8 hours, often every 4-6 hours, especially in the initial stages of continuous enteral feedings, to monitor tolerance and prevent complications such as aspiration.

B. Change the feeding bag every 24 hr:
Explanation: Changing the feeding bag and tubing at regular intervals helps prevent bacterial contamination and maintain aseptic technique. The frequency of bag changes is typically scheduled every 24 hours or according to facility protocols.

C. Flush the tube with sterile sodium chloride solution every 2 hr:
Explanation:While it is important to flush the feeding tube regularly to maintain patency, using sterile water is typically recommended unless there is a specific clinical indication for sterile sodium chloride. The frequency of flushing (usually every 4-6 hours for continuous feeding) should be determined based on the institution's protocol and the client's specific needs.

D. Position the head of the client's bed at 15 degrees:
Explanation:To reduce the risk of aspiration, the head of the bed should be elevated to at least 30-45 degrees during enteral feedings, not just 15 degrees. Elevating the head of the bed helps prevent reflux and aspiration.

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A nurse is caring for a client who requires an NG tube. After inserting the tube, the nurse tests the pH of the client's aspirate. Which of the following pH levels should the nurse identify as an indication of correct placement of the tube?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about manifestations of hypoglycemia with an adolescent who has type 1 diabetes mellitus. Which of the following manifestations should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?

Correct Answer is ["B"]

Explanation

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