A nurse is checking for proper placement of a feeding tube.
Which of the following methods is the most reliable for verification of tube placement?

Choice A rationale

Securing the catheter helps prevent it from moving, which reduces the risk of urethral trauma and infection. Proper fixation is essential for patient safety and comfort.

Choice B rationale

Urine should not be obtained from the drainage bag for specimen collection as it may be contaminated. Fresh urine samples directly from the catheter port are more accurate.

Choice C rationale

Catheter bags should be changed based on clinical need, which can be more frequent than every 3 days. This ensures hygiene and reduces infection risks.

Choice D rationale

The drainage bag should be kept below the bladder level to prevent backflow of urine, which can lead to infection.

Choice A rationale

While checking recent medication administration is important, it is not the immediate priority when a client is experiencing shortness of breath. Immediate actions should focus on assessing and improving the client's oxygenation status.

Choice B rationale

Reviewing the client’s most recent SaO2 level is useful, but not the first action to take when there is an immediate concern for the client’s oxygenation. Addressing the current low SaO2 level takes precedence.

Choice C rationale

Notifying the charge nurse is necessary, but the nurse should first attempt to quickly re-evaluate the client’s condition and try simple interventions to improve oxygenation, such as having the client cough and clear their throat.

Choice D rationale

Rechecking the SaO2 level after having the client cough and clear their throat is the appropriate first action. This can help determine if the low SaO2 reading is due to a temporary obstruction, such as mucus, and allows for a more accurate assessment of the client's respiratory status. .