which of the following techniques would the nurse use first to determine if a nasogastric tube is positioned in the stomach
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. Which of the following techniques would the nurse use first to determine if a nasogastric tube is positioned in the stomach?

Correct answer: A

Rationale: The initial way to determine if a nasogastric tube is in the stomach is to apply suction to the tube with a syringe and observe for the return of stomach contents. Then the pH of the aspirate can be measured. This is the method of choice. One would not irrigate until tube placement is confirmed. Observing for air bubbles when the free end of the tube is placed under water is an unacceptable, unsafe method of determining tube placement. Another method is to instill air into the tube with a syringe while auscultating over the epigastric area. Hearing the air enter the stomach helps ensure proper placement, but the method is not foolproof and is no longer considered an effective or preferred way to determine placement.

2. Eleanor, a 62 y.o. woman with diverticulosis is your patient. Which interventions would you expect to include in her care?

Correct answer: C

Rationale: Care for a patient with diverticulosis includes a high-fiber diet and administration of psyllium.

3. Janice is waiting for discharge instructions after her herniorrhaphy. Which of the following instructions do you include?

Correct answer: C

Rationale: Advise the patient to lose weight if obese to reduce the risk of complications after herniorrhaphy.

4. Annebell is being discharged with a colostomy, and you’re teaching her about colostomy care. Which statement correctly describes a healthy stoma?

Correct answer: A

Rationale: A healthy stoma may bleed slightly when touched initially, which is normal.

5. The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?

Correct answer: A

Rationale: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. Repositioning the client to the right side will not alleviate the cramping. Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.

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