A nurse has inserted a nasogastric tube and is planning to confirm placement of the tube prior to starting enteral feedings. What is the most accurate method for confirming placement?
1. Obtaining a radiological x-ray of the abdomen
2. Checking gastric aspirate for a pH of less than 7
3. Instilling 30 mL of air while listening with a stethoscope when placed over the fundus of the stomach
4. Determining the presence of carbon dioxide
1
Rationale 1: The appropriate method for identifying placement of the feeding tube in the stomach is visualizing the tube in the stomach on an abdominal x-ray.
Rationale 2: This is not the appropriate method for identifying placement of the feeding tube in the stomach.
Rationale 3: This is not the appropriate method for identifying placement of the feeding tube in the stomach.
Rationale 4: This is not the appropriate method for identifying placement of the feeding tube in the stomach.
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The nurse is providing care for a patient who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize?
A) The patient's swallowing ability B) The patient's airway patency C) The patient's carotid pulses D) Signs and symptoms of infection
Anthropometric measures include which of the following? Select all that apply
a. X-rays d. Hematocrit b. Height e. Hemoglobin c. Weight f. Body mass index
A nurse caring for a cognitively impaired older adult client shows an understanding of the unique clinical symptoms of constipation in this population when: (Select all that apply.)
a. checking documentation to determine if the client has had a bowel movement in the last 24-36 hours. b. questioning staff as to whether the client has any unexplained falls in the last few days. c. asking the client to name all of his or her children and grandchildren. d. requesting that the client's temperature be taken now and again in 4 hours. e. reviewing the client's food intake over the last 24-36 hours.