i encountered the following question during nclex review:
the best action to establish correct placement of a gastric tube is for the nurse to
a) aspirate for the color and ph test b) inject air while listening for the gastric gurgle c) check the results of the x-ray results of tube placement d) measure the residual volume then reinsert the aspirate
you chose:c)check the results of the x-ray results of tube placement
the correct answer is a: aspirate for the color and ph test. all of the options are safe actions. however checking the color and ph are the best actions for verification of tube placement.
i selected xray, because visualization is the best confirmation is it not? i consulted my saunders review book and it states that the most reliable method of placement confirmation is xray after initial placement. thereafter, aspiration and ph test should be used to check placement most accurately.
okay, am i missing something in this question? i was taught not to assume, but am i supposed to assume that this is after initial placement, or that the xray results are not from a current xray but from the initial placement?
the question asked best action of the nurse, the only way that i would be able to understand why this answer is correct is if checking the results of an xray is not an action of the nurse. how would you answer this question for nclex purposes, a or c, and if you could please explain your thinking.
thanks to all who answer!