A nurse is caring for an adolescent.
Admission Assessment
1400:

• Adolescent brought to emergency department by parents following a fall while skateboarding.
• Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.
• Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm.
• Abdomen soft and nontender with active bowel sounds in all four quadrants.
• Right lower extremity with open wound and displaced bone.
• Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Select the 4 findings that require follow-up.

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.

Choice A reason:
Determine previous coping skills used by the client is not appropriate. Assessing the client's previous coping skills is an essential step in the assessment phase of the therapeutic relationship, not specifically during the orientation phase. This information helps the nurse to understand the client's coping mechanisms and identify potential areas for improvement or support.
Choice B reason:
Facilitate the client's problem-solving skills is not appropriate the nurse may work on facilitating the client's problem-solving skills throughout the therapeutic relationship, including during the working phase. During this phase, the nurse and client collaborate to explore and address the client's concerns and challenges.
Choice C reason:
Assisting the client in expressing alternative behaviours is not appropriate. This action may also be part of the working phase, where the nurse helps the client explore alternative behaviours and coping strategies to address their issues and challenges.
Choice D reason:
The orientation phase is the initial stage of the therapeutic relationship where the nurse and the client get to know each other and establish the groundwork for their working relationship. During this phase, it is essential to clarify the roles and responsibilities of both the nurse and the client to ensure a clear understanding of each other's expectations.