The client had a nasogastric tube placed two days ago. Which nursing action provides the most reliable means to assess placement of a client's nasogastric tube, prior to each medication administration?

Place end of tube in water and observe for bubbling.

Using auscultation technique.

Measure pH of aspirates.

Radiographic confirmation.

Answer and Explanation

The Correct Answer is D

Radiographic confirmation. Radiographic confirmation is the most reliable method to verify the placement of nasogastric tubes, and it is considered the gold standard. The nurse should use it to confirm placement initially and periodically to ensure that the tube is in the stomach and not in the lungs or esophagus.

Option A, placing the end of the tube in water and observing for bubbling, is incorrect because it is not a reliable method, and it can cause aspiration or infection.

Option B, using the auscultation technique, is incorrect because it can lead to misinterpretation of bowel sounds, and it is not reliable.

Option C, measuring pH of aspirates, is incorrect because it is not a reliable method, and it can be affected by several factors, including medications, stress, and nutritional status.

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Correct Answer is A

Explanation

Increased pulse rate, adventitious breath sounds. Guillain-Barré syndrome (GBS) is a rare autoimmune disorder that affects the peripheral nervous system. It can cause weakness, paralysis, and difficulty breathing. Increased pulse rate and adventitious breath sounds, such as crackles or wheezes, may indicate that the client is experiencing respiratory distress and needs oral suctioning. Increased pulse rate and respirations of 16 breaths/minute, choice B, may indicate anxiety or pain but are not necessarily indicative of the need for oral suctioning.

A. Ulcerative colitis. B. Appendicitis. C. Peritonitis. D. Diverticulitis.

Correct Answer is C

Explanation

Peritonitis. The assessment findings of an absence of bowel sounds and a very rigid abdomen in a client with severe abdominal pain, nausea, and vomiting are indicative of peritonitis. Peritonitis is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs. The inflammation can occur due to an infection or other causes, and it can cause abdominal pain, nausea, vomiting, and a rigid abdomen. An absence of bowel sounds is also a characteristic finding of peritonitis.

A is not the correct answer because ulcerative colitis is a chronic inflammatory bowel disease that causes inflammation and ulcers in the colon and rectum.

B is not the correct answer because appendicitis is inflammation of the appendix, which can cause right lower quadrant abdominal pain, nausea, vomiting, and fever.

D is not the correct answer because diverticulitis is inflammation of one or more diverticula, which are small pouches that can form in the colon. It can cause left lower quadrant abdominal pain, fever, diarrhea, or constipation.

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The client had a nasogastric tube placed two days ago. Which nursing action provides the most reliable means to assess placement of a client's nasogastric tube, prior to each medication administration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

Correct Answer is A

Explanation

A client is being seen in the clinic for severe abdominal pain with nausea and vomiting. The nurse assesses the abdomen and notes an absence of bowel sounds and a very rigid abdomen. What would these assessment findings most likely indicate?

Correct Answer is C

Explanation

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