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.