84 a nurse is caring for a semiconscious client who

84.
A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the
administration of enteral feeding. Which of the following methods should the nurse use toverify correct
tube placement? (SATA)
A. Auscultate injected air
-incorrect: Auscultating air injected into an NG tube is not a reliable method of determiningcorrect
NG tube placement.
B. Verify the initial X-Ray examination C.
Measure the length of the exposed tubeD.
Determine the pH of aspirated fluid
-The nurse should confirm the NG tube placement by checking the X-ray results following theinsertion
of the NG tube. In addition, the nurse should check the length of the NG tube that is exposed by
comparing the markings on the tube to the client‟s nose to verify tube placement.
E. Check the aspirated fluid for glucose
-incorrect: Checking for glucose in the aspirated fluid is not a reliable method of determiningcorrect
NG tube placement.
85.
A nurse is preparing to insert an NG tube for a client. Which of the following actions willhelp
facilitate the insertion of the tube? (SATA)
A. coat the tip of the tube with a water-soluble lubricant
B. Ask the client to swallow water while the tube enters her throat

-Lubricating the tube eases its passage. A water-based gel because it will dissolve if the tube slips into
the client‟s airway, whil e using petroleum jelly could cause respiratory problems. Swallowing water
reduces the risk of gagging and aspiration and helps propel the tube down theesophagus. Hyperextending
the neck reduces the curvature of the nasopharynx, which facilitatesthe insertion of the NG tube.
C. Place the coiled tube in ice chips prior to insertion
-incorrect: Ice makes NG tubes rigid, increasing the risk of trauma to mucous membranes.
D. Tell the client to tilt her head backward as insertion begins
-Lubricating the tube eases its passage. A water-based gel because it will dissolve if the tube slips into
the client‟s airway, while using petroleum jelly could cause respiratory problems. Swallowing water
reduces the risk of gagging and aspiration and helps propel the tube down theesophagus. Hyperextending
the neck reduces the curvature of the nasopharynx, which facilitatesthe insertion of the NG tube.
E. Instruct the client to bear down during insertion
-incorrect: Bearing down is helpful during the insertion of a urinary catheter, not an NG tube.
86.
A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention.
Which of the following pieces of information should the nurse include in the teaching?
A. The wound edges are well-approximated
-incorrect: Primary intention involves the closing of the wound using sutures or staples at thetime the
incision is made; the suture line edges become well-approximated during healing.