The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35. Based on this information, which action should the nurse take at this time?

Document that the nasogastric tube is in the correct place.

Notify the health care provider.

Check for placement by auscultating for air injected into the tube.

Retest the pH using another strip.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Documenting that the nasogastric tube is in the correct place is not appropriate in this scenario. A gastric pH of 7.35 is too high for stomach contents, which typically have a pH between 1.5 and 3.5. This high pH suggests that the tube may be misplaced, possibly in the respiratory tract or another non-gastric location. Therefore, documenting the tube as correctly placed could lead to serious complications if the tube is indeed misplaced.

Choice B Reason:

Notifying the health care provider is the most appropriate action. A pH of 7.35 is indicative of a potential misplacement of the nasogastric tube. The health care provider needs to be informed immediately to take corrective actions, such as ordering an X-ray to confirm the tube’s placement or re-evaluating the tube’s position. This step is crucial to ensure patient safety and prevent complications such as aspiration pneumonia or other adverse effects.

Choice C Reason:

Checking for placement by auscultating for air injected into the tube is an outdated and unreliable method. This technique can sometimes give false assurance of correct placement, as the sound of air can be heard even if the tube is in the respiratory tract. Current best practices recommend using pH testing and radiographic confirmation for accurate placement verification.

Choice D Reason:

Retesting the pH using another strip might seem like a reasonable step, but it is not the best immediate action. If the initial pH test shows a value of 7.35, it is unlikely that retesting will yield a significantly different result. The priority should be to notify the health care provider to address the potential misplacement promptly.

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Correct Answer is ["A","C","E"]

Explanation

Choice A Reason:

Weight loss.

Weight loss is a common symptom of hyperthyroidism. This condition speeds up the body’s metabolism, causing the body to burn calories more quickly than usual. Despite an increased appetite, individuals with hyperthyroidism often experience significant weight loss. This symptom is a direct result of the overproduction of thyroid hormones, which increases the metabolic rate.

Choice B Reason:

Intolerance to cold.

Intolerance to cold is not typically associated with hyperthyroidism; it is more commonly a symptom of hypothyroidism. Hyperthyroidism usually causes heat intolerance due to the increased metabolic rate, which raises the body’s temperature. Therefore, this choice is not relevant to hyperthyroidism.

Choice C Reason:

An elevated systolic blood pressure.

An elevated systolic blood pressure can be a symptom of hyperthyroidism. The increased levels of thyroid hormones can cause the heart to work harder, leading to higher blood pressure. This symptom is important to monitor as it can lead to further cardiovascular complications if left untreated.

Choice D Reason:

A heart rate of 90 bpm.

A heart rate of 90 bpm is within the normal range for adults and is not specifically indicative of hyperthyroidism. Hyperthyroidism typically causes a rapid or irregular heartbeat, often exceeding 100 bpm. Therefore, this choice does not accurately reflect a clinical manifestation of hyperthyroidism.

Choice E Reason:

Increased fatigability.

Increased fatigability is a common symptom of hyperthyroidism. Despite the increased metabolic rate, individuals with hyperthyroidism often feel tired and weak. This paradoxical symptom occurs because the body’s systems are overworked and cannot sustain the heightened activity levels, leading to fatigue.

A. Increase in the temperature from 37.5°C (99.5°F) to 38.6°C (101.5°F) B. Decrease in the urinary output from 50 to 30 mL per hour C. Increase in the heart rate from 88 to 110/min D. Decrease in the respiratory rate from 20 to 16/min

Correct Answer is B

Explanation

Choice A reason: An increase in temperature is not a primary indicator of hypovolemic shock. While fever can occur due to infection or inflammation, it is not directly related to hypovolemic shock, which is primarily characterized by a significant loss of blood or fluids leading to decreased perfusion and oxygenation of tissues.

Choice B reason: A decrease in urinary output is a critical sign of hypovolemic shock. When the body loses a significant amount of blood or fluids, the kidneys receive less blood flow, leading to reduced urine production. This is a compensatory mechanism to conserve fluids and maintain blood pressure. Normal urine output is typically around 30 to 50 mL per hour, so a drop below this range is concerning.

Choice C reason: An increase in heart rate is a common response to hypovolemic shock as the body attempts to maintain cardiac output and blood pressure despite the loss of blood volume. Tachycardia (increased heart rate) is one of the early signs of shock, indicating that the heart is working harder to pump blood to vital organs.

Choice D reason: A decrease in respiratory rate is not typical of hypovolemic shock. In fact, hypovolemic shock often leads to an increased respiratory rate (tachypnea) as the body tries to compensate for decreased oxygen delivery to tissues. A decrease in respiratory rate could indicate other issues but is not a hallmark of hypovolemic shock.

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The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35. Based on this information, which action should the nurse take at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What clinical manifestations does the nurse recognize would be associated with a diagnosis of hyperthyroidism? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

Correct Answer is B

Explanation

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