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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiced. “I will wear gloves when changing the client’s hospital gown.”
Choice A rationale:
Cleaning reusable equipment with isopropyl alcohol is not effective against Clostridium difficile spores. Equipment should be cleaned with a sporicidal disinfectant to ensure the removal of C.difficile spores.
Choice B rationale:
Alcohol-based hand sanitizers are not effective against C. difficile spores.Hand hygiene should be performed with soap and water after contact with the client or their environment.
Choice C rationale:
Wearing a mask within 3 feet of the client is not necessary for C. difficile infection, as it is not transmitted via respiratory droplets.The primary mode of transmission is through contact with contaminated surfaces or feces.
Choice D rationale:
Wearing gloves when changing the client’s hospital gown is essential to prevent the transmission of C. difficile spores.Gloves should be worn for all contact with the client or their environment
Correct Answer is A
Explanation
Choosing the best intervention for a client with fever due to infection:
The most appropriate intervention for a client with fever due to infection depends on various factors, including the severity of the fever, the client's age and overall health, and their individual preferences. Let's analyze each option and explain its rationale:
a. Encourage fluid intake of 2,500 mL/day.
Rationale:
- Pros:Fever often leads to increased sweating and fluid loss through respiration. Maintaining adequate hydration is crucial to prevent dehydration, which can worsen discomfort and potentially lead to complications like organ dysfunction. Encouraging a fluid intake of 2,500 mL/day is generally recommended for adults with fever, although individual needs may vary based on factors like body size and activity level.
- Cons:While hydration is essential, forcing fluids on a client who experiences nausea or vomiting can be counterproductive. Additionally, some clients with certain medical conditions, like heart failure, may require fluid restriction, making this option inappropriate.
b. Maintain the environmental temperature at 16°C to 18°C (60°F to 65°F).
Rationale:
- Cons:Excessively cool environments can trigger shivering, which actually increases body heat production and can worsen the fever. Additionally, maintaining such a low room temperature can be uncomfortable for the client and may increase their risk of chills.
c. Immerse the client in cold water.
Rationale:
- Cons:Immersing a client in cold water, like a bath, can be a dangerous and counterproductive intervention. The sudden chill can trigger violent shivering, significantly increasing body heat production and potentially causing shock. Moreover, rapid cooling can be uncomfortable and even risky for people with certain health conditions like heart disease.
d. Assist the client to ambulate.
Rationale:
- Cons:While ambulation is generally encouraged for healthy clients, it may not be suitable for everyone with a fever. Depending on the severity of the fever and the client's overall condition, ambulation could be tiring and even unsafe. In some cases, rest may be more appropriate to promote comfort and recovery.
Therefore, the most appropriate intervention for a client with fever due to infection is:
a. Encourage fluid intake of 2,500 mL/day.
Remember:
- Individualize care based on the client's specific needs and preferences.
- Monitor the client's response to interventions and adjust as needed.
- Consult with the healthcare provider for guidance on managing the fever and addressing any underlying infection.
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