A nurse is checking for the 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.
Auscultate for air insufflation.
Request a chest x-ray.
Check the pH level of gastric contents.
The Correct Answer is C
Choice A Reason:
Verifying the bilirubin level of the tube contents is incorrect. Measuring bilirubin levels in the tube contents is not a standard or reliable method for confirming tube placement. It's not an established or recommended technique for this purpose.
Choice B Reason:
Auscultating for air insufflation is incorrect. Auscultation for air insufflation involves injecting air into the tube and listening for bubbling sounds over the stomach area. While this method is commonly used, it can sometimes yield inconsistent or inconclusive results, especially in patients with certain conditions or situations where air movement might not be detectable.
Choice C Reason:
Request a chest x-ray is correct. Obtaining a chest x-ray is the most reliable method to confirm the placement of a feeding tube, especially when the tube is newly inserted or if there are any doubts about its location. A chest x-ray can accurately visualize the position of the tube within the gastrointestinal tract, ensuring it is in the intended location before any feedings or medications are administered.
Choice D Reason:
Checking the pH level of gastric contents is incorrect. Measuring the pH level of aspirated gastric contents can provide information about the acidity of the fluid, indicating gastric placement (pH below 5) in most cases. However, the pH can be influenced by various factors like medications, enteral feeding solutions, or certain medical conditions, making it less reliable than a chest x-ray for definitive confirmation of tube placement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
"Aren't you interested in learning how to perform this test?" is incorrect. This response might come across as accusatory or judgmental, potentially making the client feel uncomfortable or defensive, further hindering communication.
Choice B Reason:
"Let's talk about what you're thinking." Is correct. This response acknowledges the client's distraction and aims to understand and address their thoughts or concerns that might be hindering their focus. It invites the client to express any worries or questions they might have, allowing the nurse to provide reassurance or clarification.
Choice C Reason:
"I'll discuss this with your partner instead." Is incorrect. Redirecting the conversation to the client's partner without understanding the client's concerns directly could undermine the client's autonomy and miss the opportunity to address their needs.
Choice D Reason:
"Is this something you think you can do?" is incorrect. While this question aims to assess the client's confidence, it might not effectively address the underlying reason for the client's distraction or encourage open communication about their concerns.
Correct Answer is A
Explanation
Choice A Reason:
To an employer for a pre-employment screening is correct. Generally, healthcare information disclosure to an employer for pre-employment screening requires the client's written consent. The Health Insurance Portability and Accountability Act (HIPAA) and other privacy regulations typically protect a client's health information from disclosure to employers without explicit authorization from the client.
Choice B Reason:
To a medical interpreter service on behalf of a client is incorrect. In situations where a medical interpreter service is required to facilitate communication between the healthcare provider and the client, limited disclosure of health information may be necessary to ensure proper care. However, the information shared should be relevant to the immediate healthcare needs and should not exceed what's necessary for effective communication.
Choice C Reason:
To a family member when the client is not available is incorrect. In certain circumstances, especially if the client is incapacitated or unavailable, disclosing limited health information to a family member might be necessary for the client's best interests, such as for care coordination or emergencies. However, the information shared should be limited to what's essential and relevant to the situation.
Choice D Reason:
To an insurance agency in regard to a life insurance policy is incorrect. Health information disclosure to an insurance agency might be permitted in the context of processing a life insurance policy, typically under the Health Insurance Portability and Accountability Act (HIPAA) and as allowed by state laws. However, this disclosure is usually limited to information necessary for underwriting the policy and may not require the client's explicit written consent.
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