Author Question: The nurse needs to verify feeding tube placement using the gastrointestinal (GI) pH measurement ... (Read 51 times)

danielfitts88 · **on:** Jul 22, 2018

The nurse needs to verify feeding tube placement using the gastrointestinal (GI) pH measurement test. The NG tube placement was confirmed via x-ray 6 hours ago. After several attempts, the nurse is unable to aspirate GI fluid from the tube.

The tube is secure and the external marking of the tube are in the original place. The patient appears to be tolerating the tube feedings and is not experiencing any distress. What should the nurse do? a. Contact the health care professional to order another x-ray for placement verification.
b. Instill 60 mL of air to check the placement with a stethoscope.
c. Increase the amount of water given to the patient to prevent GI distress.
d. Assume the tube is in the correct place.

Question 2

The nurse has to insert a nasogastric tube for the purpose of temporary tube feedings. To determine the length of the tube, the nurse should use which measurement?

a. Tip of the nose to the xiphoid process of the sternum and add an additional 20 cm
b. Tip of the chin to the earlobe to xiphoid process of the sternum
c. Tip of nose to the earlobe to xiphoid process of the sternum
d. Tip of the earlobe to the nose to the umbilicus

catron30 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D
If, after repeated attempts, it is not possible to aspirate fluid from a tube that was originally established by x-ray examination to be in desired position, and (a) there are no risk factors for tube dislocation, (b) there is no change in the external marked tube length, and (c) patient is not experiencing difficulty, assume the tube is correctly placed. Another x-ray is not needed. Flushing the tube with 30 ml, not 60, of air is to help obtain the aspirate, not to check placement. Checking for placement with air is an outdated process. Increasing the water will not check placement.

Answer to Question 2

C
Determine the length of the tube you will insert, and mark location on the tube or mark with tape. Measure the distance from the tip of nose to earlobe to xiphoid process of the sternum. Adding an additional length of half the distance from the xiphoid process to the umbilicus may aid in seating the tube further into the stomach. Add an additional 20 to 30 cm (8 to 12 inches) for a nasointestinal tube. Chin to the earlobe to the xiphoid process and the tip of the earlobe to the nose to the umbilicus will provide an inaccurate length.