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 D

Explanation

Cerebrospinal fluid is cloudy in nature. Cloudy cerebrospinal fluid is a sign of infection or inflammation in the central nervous system, and lumbar puncture can be used to obtain cerebrospinal fluid for diagnostic purposes. The nurse should report this finding immediately to the physician for further evaluation and management.

Choice A, client states a piercing feeling, is incorrect because a piercing feeling is common during the procedure due to the insertion of the needle into the subarachnoid space.

Choice B, physician maintains aseptic procedure, is incorrect because maintaining aseptic technique during the procedure is standard protocol to prevent infection.

Choice C, client states a pressure relief in the head, is incorrect because this is not a concerning finding during the procedure.

A. Orange juice. B. Glucagon. C. Cortisone. D. Intravenous dextrose solution.

Correct Answer is D

Explanation

A blood glucose reading of 48 is considered low and requires immediate intervention to raise the client's blood sugar. Intravenous dextrose solution is the fastest way to raise blood sugar levels in an unconscious client. Glucagon and cortisone can also be used to raise blood sugar levels, but they are not the first-line treatment for hypoglycemia.

Choice A, orange juice, is not appropriate for an unconscious client as they cannot swallow or drink.

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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 assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern?

Correct Answer is D

Explanation

The nurse is checking the blood glucose of a client and has a reading of 48. The client is not easily awakened and only responds with a groan. What will the nurse administer to raise the blood glucose level?

Correct Answer is D

Explanation

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