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?
Verify the bilirubin level of the tube contents.
Check the pH level of gastric contents.
Auscultate for air insufflation.
Request a chest x-ray.
The Correct Answer is D
Choice A rationale
Verifying the bilirubin level of the tube contents is not a standard or reliable method for checking the placement of a feeding tube. Bilirubin is a bile pigment found in the liver and bile ducts, and its levels are not indicative of tube placement in the gastrointestinal tract.
Choice B rationale
Checking the pH level of gastric contents can help determine if the tube is in the stomach, but it is not the most reliable method. Gastric pH is typically acidic (1.5-3.5), but the pH can vary, and this method does not rule out respiratory placement or other incorrect placements.
Choice C rationale
Auscultating for air insufflation involves listening for the sound of air injected through the tube into the stomach. However, this method is not reliable as it does not confirm the exact location of the tube and can give false positives if the tube is in the esophagus or respiratory tract.
Choice D rationale
Requesting a chest x-ray is the most reliable method for verifying feeding tube placement. It provides a clear visual confirmation of the tube's location, ensuring it is correctly positioned in the stomach or small intestine and not in the respiratory tract or other incorrect locations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Drinking citrus juice with meals can irritate the bladder and exacerbate urinary incontinence due to the high acidity in citrus fruits. It is not recommended for individuals with urinary incontinence.
Choice B rationale
Training the bladder by voiding every 5 hours is too infrequent for most individuals. Bladder training usually involves more frequent voiding intervals to gradually increase the bladder's capacity to hold urine.
Choice C rationale
Applying adult diapers at bedtime can be useful in managing nighttime incontinence but does not address the underlying issue or provide a long-term solution for urinary incontinence.
Choice D rationale
Performing pelvic-muscle exercises, also known as Kegel exercises, can strengthen the pelvic floor muscles and improve bladder control, making it an effective method for managing urinary incontinence.
Correct Answer is D
Explanation
Choice A rationale
Placing the client's arms above her head prior to logrolling can cause discomfort and injury, especially after spinal surgery. Arms should be kept at the sides to maintain alignment.
Choice B rationale
Placing the client in semi-Fowler's position before logrolling is incorrect. The semi-Fowler's position is not stable for logrolling and does not align the spine correctly for safe movement.
Choice C rationale
Placing the bed in the lowest position before logrolling can make the process more difficult and unsafe. The bed should be at a height that allows proper body mechanics for the caregiver.
Choice D rationale
Placing a pillow between the client's legs prior to logrolling helps maintain spinal alignment and prevents twisting of the spine, which is crucial after a laminectomy.
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