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

Change in bowel habits. Change in bowel habits, such as diarrhea, constipation, or a change in stool consistency, is a common early symptom of colon cancer. The nurse should advise clients over age 50 to report any changes in bowel habits to their primary care provider for early intervention.

Choice B is incorrect because abdominal cramping is a common symptom of irritable bowel syndrome and not necessarily an early symptom of colon cancer.

Choice C is incorrect because daily bowel movements are considered normal for some individuals and are not necessarily indicative of colon cancer.

Choice D is incorrect because excess gas is not an early symptom of colon cancer.

A. Fluid accumulation under the arm. B. Drainage from the area. C. Reddened area around the breast. D. Enlargement of the arm or hand.

Correct Answer is A

Explanation

Fluid accumulation under the arm. The presence of fluid accumulation (edema) under the arm may indicate the spread of breast cancer to the lymph nodes. The physician should be notified, and further evaluation and treatment may be necessary.

Option B: Drainage from the area is not a correct answer as it may indicate a surgical site infection or an abscess, but not necessarily the spread of cancer.

Option C: Reddened area around the breast is not a correct answer as it may indicate a skin infection or inflammation, but not necessarily the spread of cancer.

Option D: Enlargement of the arm or hand is not a correct answer as it may indicate lymphedema, which is a swelling due to lymphatic system damage, but not necessarily the spread of cancer.

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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 talking with a group of clients that are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider?

Correct Answer is A

Explanation

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Correct Answer is A

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