The nurse has just inserted a nasogastric tube for gastric ...

[wrbasek0]

The nurse has just inserted a nasogastric tube for gastric suction. What is the most reliable test for confirming tube placement?
 
  1. Place the stethoscope over the stomach and listen while inserting water into the tube for a swishing sound.
  2. Place the stethoscope over the stomach and listen while inserting air into the tube for a swishing sound.
  3. Aspirate stomach contents and check the acidity using a pH test strip.
  4. Connect the tube to suction and observe the contents.

Question 2

Which nursing intervention would the nurse implement to decrease the risk of a surgical client developing thrombophlebitis?
 
  1. Administer an anticoagulant
  2. Cough every 2 hours
  3. Intake and output every 2 hours
  4. Early ambulation

[cam1229]

Answer to Question 1

Correct Answer: 3
Rationale 1: Water should not be inserted into the tube until placement is confirmed.
Rationale 2: This is done to ensure placement however it is not the most reliable test.
Rationale 3: Aspirate stomach contents and check the acidity using a pH test strip is the most reliable test to confirm tube placement.
Rationale 4: Connecting the tube to suction should not be done until tube placement has been confirmed.

Answer to Question 2

Correct Answer: 4
Rationale 1: Anticoagulant therapy must be prescribed by a physician.
Rationale 2: Coughing every 2 hours will reduce the client's risk of developing pneumonia or atelectasis.
Rationale 3: Measuring intake and output every 2 hours assesses the client's renal function.
Rationale 4: Early ambulation, leg exercises, antiemboli stockings, SCDs, and adequate fluid intake are all interventions to reduce the risk for thrombophlebitis.

[wrbasek0]

TYSM

[nanny]

Excellent