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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Before and after applying a cast, it is essential to assess the client's circulation, movement, and sensation to ensure there is no damage to the nerves or blood vessels. Assessing cardiac and respiratory status is not as relevant to cast application. ROM status is important but can be assessed by assessing movement and sensation. Renal and hepatic function are not directly related to cast application.
Correct Answer is B
Explanation
Enuresis. Enuresis is the involuntary discharge of urine after the age at which bladder control should have been established. It is a normal finding for children up to the age of 5 years. Hematuria, Anuria, and Dysuria are abnormal findings related to the urinary system and are not normal findings for a 3-year-old.
Choice A, Hematuria, is incorrect because it is an abnormal finding related to the urinary system.
Choice C, Anuria, is incorrect because it is an abnormal finding related to the urinary system.
Choice D, Dysuria, is incorrect because it is an abnormal finding related to the urinary system.
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