A nurse is preparing to administer enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify the correct placement of the NG tube?

Check the pH of the gastric aspirate.

Observe the color of the gastric aspirate after adding blue dye to the formula.

Auscultate over the epigastrium.

Measure the length of the inserted NG tube.

Answer and Explanation

The Correct Answer is A

A: Correct. Checking the pH of the gastric aspirate is the most reliable method to verify the correct placement of the NG tube. Gastric aspirate typically has an acidic pH (pH < 5), indicating that the tube is in the stomach.
B: Observing the color of the gastric aspirate after adding blue dye to the formula is not a standard or recommended method for verifying NG tube placement.
C: Auscultating over the epigastrium may help to identify the presence of air in the stomach, but it does not confirm that the NG tube is correctly placed in the stomach or the intestines.
D: Measuring the length of the inserted NG tube can help determine the distance from the nose to the stomach, but it does not ensure correct placement in the stomach.

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Correct Answer is ["B","D","E"]

Explanation

A: A full bounding pulse is a sign of increased fluid volume or fluid overload, not fluid volume deficit.
B: Cool extremities can be an indication of decreased peripheral perfusion, which may occur in fluid volume deficit.
C: Moist crackles in the lungs are an indication of fluid volume excess or pulmonary congestion, not fluid volume deficit.
D: Orthostatic hypotension, which is a drop in blood pressure when changing from lying to standing, can be a sign of fluid volume deficit due to inadequate blood volume.
E: Flat neck veins are an indication of decreased venous return and can occur in fluid volume deficit.

A. Check that the restraint is tied to a fixed frame of the bed. B. Pad bony prominences on the wrist. C. Remove the restraint every 4 hr to allow movement. D. Tie the restraint with a knot that will tighten when pulled.

Correct Answer is B

Explanation

A. Check that the restraint is tied to a fixed frame of the bed: Restraints should never be tied to the side rails or a fixed frame of the bed, as this can lead to serious injuries. Restraints should be secured to the bed frame using quick-release ties to ensure safety.
B. Pad bony prominences on the wrist: Correct. Padding bony prominences on the wrist is an important step in the use of restraints to prevent skin breakdown and pressure injuries.
C. Remove the restraint every 4 hr to allow movement: While repositioning and releasing restraints periodically is essential for the client's comfort and safety, it is not appropriate to remove wrist restraints entirely every 4 hours, as they were prescribed for a specific purpose.
D. Tie the restraint with a knot that will tighten when pulled: Restraints should never be tied with a knot that can tighten when pulled, as this can cause harm to the client and restrict blood flow. Restraints should be secured using quick-release ties to allow for easy removal in
emergencies.

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A nurse is preparing to administer enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify the correct placement of the NG tube?

Nursing Test Bank

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A nurse is preparing to administer enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify the correct placement of the NG tube?