Nokea
A new graduate nurse is assigned to a 30-year-old female requiring NG tube feeding. The preceptor reminds the graduate nurse to check placement of the NG tube before administering the feeding. The best way to do this is by
- A. verifying placement with an X-ray before each feeding.
- B. aspirating gastric contents and testing the contents on a pH paper.
- C. auscultating bowel sounds after administering a 30 cc air bolus.
- D. auscultating bowel sounds after administering the first 10 cc of tube feeding.
Correct Answer: B
Rationale: Aspirating gastric contents and checking pH (≤5.5 indicates gastric placement) is the most reliable bedside method to confirm NG tube placement.
You may also like to solve these questions
The client with preeclampsia is admitted to the unit with an order for magnesium sulfate IV. Which action by the nurse indicates a lack of understanding of magnesium sulfate?
- A. The nurse places a sign over the bed not to check blood pressures in the left arm.
- B. The nurse obtains an IV controller.
- C. The nurse inserts a Foley catheter.
- D. The nurse darkens the room.
Correct Answer: A
Rationale: Avoiding blood pressure checks in one arm is unrelated to magnesium sulfate; the other actions align with monitoring and managing side effects.
The client has an order for FeSO4 liquid. Which method of administration would be best?
- A. Administer the medication with milk
- B. Administer the medication with a meal
- C. Administer the medication with orange juice
- D. Administer the medication undiluted
Correct Answer: C
Rationale: Administering FeSO4 with orange juice enhances iron absorption due to its vitamin C content.
A client has experienced 48 hours of severe repeated bouts of vomiting. Which acid-base imbalance is of most concern?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: D
Rationale: Severe vomiting causes loss of gastric acid, leading to metabolic alkalosis (D). Respiratory imbalances (A, B) and metabolic acidosis (C) are less likely.
The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:
- A. Take the blood pressure, pulse, and temperature
- B. Ask the client to rate his pain on a scale of 0-5
- C. Watch the client's facial expression
- D. Ask the client if he is in pain
Correct Answer: B
Rationale: A pain scale provides a reliable, subjective measure of pain.
The nurse is caring for a client receiving hemodialysis. During hemodialysis, the client becomes anxious, experiencing tachypnea and hypotension. The nurse suspects which complication of hemodialysis?
- A. air embolism
- B. clotting of the graft site
- C. dialysis encephalopathy
- D. disequilibrium syndrome
Correct Answer: D
Rationale: Disequilibrium syndrome can occur during hemodialysis due to rapid shifts in fluids and electrolytes, causing symptoms like anxiety, tachypnea, and hypotension.