A nurse is inserting an NG tube for a client who has a new prescription for enteral feedings. Which of the following actions should the nurse take to verify the placement of the client's tube? (Select all that apply.).

Measure the amount of aspirate in the NG tube.

Flush the tube with 50 mL of tap water.

Examine the color of aspirated secretions.

Measure the pH of the client's aspirate.

Obtain an x-ray of the client's chest and abdomen.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale:

Measuring the amount of aspirate in the NG tube is one way to verify the placement of the tube. Aspirate should be tested for color, pH, and other characteristics to ensure proper positioning.

Choice B rationale:

Flushing the tube with tap water doesn't directly verify tube placement. This action might inadvertently introduce air into the tube, potentially leading to inaccurate assessment results.

Choice C rationale:

Examining the color of aspirated secretions is an essential step in verifying tube placement. Different colors of aspirate can indicate different anatomical locations, helping to ensure the tube is properly positioned.

Choice D rationale:

Measuring the pH of the client's aspirate is another important method to verify NG tube placement. Gastric aspirate tends to be acidic, while respiratory aspirate is usually more alkaline.

Choice E rationale:

Obtaining an x-ray of the client's chest and abdomen is a definitive method for confirming NG tube placement. It provides direct visualization of the tube's location and ensures accuracy.

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Correct Answer is C

Explanation

The correct answer is C.

Choice A reason: Walking on the client’s right side is incorrect because the nurse should walk on the client’s left side. This is the weaker side and the side where support is most needed.

Choice B reason: Instructing the client to look down at their feet when ambulating is incorrect because the client should be instructed to look straight ahead, not down at their feet, to maintain balance and prevent falls.

Choice C reason: Have the client sit on the side of the bed for at least 60 seconds before ambulating. This allows the nurse to assess the client’s tolerance and readiness for ambulation, and it helps prevent dizziness or fainting due to orthostatic hypotension.

Choice D reason: Placing the gait belt securely around the client’s lower chest is incorrect because the gait belt should be placed around the client’s waist, not the lower chest. This provides a secure grip for the nurse and allows for safer ambulation.

A. Emergency contact information. B. Intake and output summary. C. List of community resources. D. Basic demographic data.

Correct Answer is C

Explanation

The correct answer is choice c. List of community resources.

Choice A rationale:

Emergency contact information is typically found in the patient’s admission records or demographic section, not in the discharge summary.

Choice B rationale:

Intake and output summary is part of the daily nursing notes or fluid balance chart, not usually included in the discharge summary.

Choice C rationale:

The discharge summary often includes a list of community resources to support the patient after discharge, such as contact information for follow-up care, support groups, or home health services.

Choice D rationale:

Basic demographic data is recorded in the patient’s initial admission records and is not typically repeated in the discharge summary.

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A nurse is inserting an NG tube for a client who has a new prescription for enteral feedings. Which of the following actions should the nurse take to verify the placement of the client's tube? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to assist a client who has left-sided weakness to ambulate using a gait belt. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is reviewing data in a client's medical record. Which of the following information should the nurse expect to find in the discharge summary section?

Correct Answer is C

Explanation

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