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
Keeping the client's room well lit is not typically beneficial for pain management and may even be counterproductive for clients who need rest or reduced sensory stimuli to manage pain effectively.
Choice B rationale
Encouraging the client to abstain from distracting activities is not recommended. Distraction techniques, such as engaging in activities, can be effective in reducing the client's perception of pain.
Choice C rationale
Ensuring that the client's room is kept at a cool temperature may not be effective for pain relief and might cause discomfort, especially if the client prefers warmth.
Choice D rationale
Playing music in the client's room can serve as a distraction and has been shown to reduce the perception of pain. Music therapy can induce relaxation, reduce anxiety, and create a calming environment.
Correct Answer is A
Explanation
Choice A rationale
Flexing hips and knees when assisting the client to a standing position uses proper body mechanics, reducing the risk of injury to both the nurse and the client. It provides a stable base of support during the transfer.
Choice B rationale
Pivoting on the foot farthest from the bed when assisting the client into the chair is incorrect. The nurse should pivot on the foot closest to the bed to maintain balance and control during the transfer.
Choice C rationale
Standing on the client's stronger side when moving the client into the chair is incorrect. The nurse should stand on the client's weaker side to provide support and prevent falls.
Choice D rationale
Raising the bed to waist level before moving the client is incorrect as it may not provide the best ergonomic position for the transfer. The bed should be at a height that ensures the nurse’s safety and facilitates the client's movement.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
