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Checking for placement by auscultating for air injected into the tube is an outdated and unreliable method.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","B","C","D"]

Explanation

Choice A reason: Monitoring the heart rate is crucial when administering amiodarone, as this drug can cause bradycardia (a slower than normal heart rate). Amiodarone affects the electrical conduction system of the heart, and close monitoring helps ensure that the heart rate remains within a safe range. The normal resting heart rate for adults is typically between 60 and 100 beats per minute.

Choice B reason: Respiratory rate monitoring is essential because amiodarone can cause pulmonary toxicity, which may manifest as interstitial pneumonitis or pulmonary fibrosis. Early detection of respiratory changes can help prevent severe complications. The normal respiratory rate for adults is 12 to 20 breaths per minute.

Choice C reason: Monitoring heart rhythm is necessary because amiodarone is used to treat arrhythmias, and it can also cause new arrhythmias or exacerbate existing ones. Continuous ECG monitoring helps detect any abnormal rhythms early, allowing for prompt intervention. Normal sinus rhythm is characterized by a regular rhythm with a rate of 60 to 100 beats per minute.

Choice D reason: Cardiac output monitoring is important because amiodarone can affect the contractility of the heart and overall cardiac function. Cardiac output is a measure of the amount of blood the heart pumps in one minute, and it is crucial for ensuring adequate tissue perfusion. Normal cardiac output ranges from 4 to 8 liters per minute in adults.

A. Increased temperature B. Increased respiratory rate C. Increased hematocrit D. Increased heart rate E. Increased blood pressure

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

Explanation

Choice A: Increased Respiratory Rate

Fluid overload, also known as hypervolemia, can lead to an increased respiratory rate. This occurs because the excess fluid in the body can accumulate in the lungs, leading to pulmonary congestion and edema. As a result, the body attempts to compensate by increasing the respiratory rate to improve oxygenation and remove excess carbon dioxide. Normal respiratory rate for adults is typically between 12-20 breaths per minute. An increased respiratory rate above this range can indicate fluid overload.

Choice B: Increased Heart Rate

An increased heart rate, or tachycardia, is another common finding in clients with fluid overload. The heart has to work harder to pump the excess fluid throughout the body, leading to an increased heart rate. This is a compensatory mechanism to maintain adequate cardiac output and tissue perfusion. Normal resting heart rate for adults is between 60-100 beats per minute. A heart rate above this range can be indicative of fluid overload.

Choice C: Increased Blood Pressure

Fluid overload can also result in increased blood pressure, or hypertension. The excess fluid in the bloodstream increases the volume of blood that the heart has to pump, leading to higher pressure within the arteries. This can strain the cardiovascular system and lead to complications if not managed properly. Normal blood pressure is typically around 120/80 mmHg. Blood pressure readings consistently above this range can suggest fluid overload.

Choice D: Increased Hematocrit

Increased hematocrit is not typically associated with fluid overload. Hematocrit is the proportion of red blood cells in the blood. In cases of fluid overload, the hematocrit level is usually decreased due to the dilutional effect of the excess fluid. Therefore, this choice is incorrect.

Choice E: Increased Temperature

Increased temperature is not a common finding in fluid overload. Fever or elevated body temperature is more commonly associated with infections or inflammatory conditions. Fluid overload does not typically cause an increase in body temperature. Therefore, this choice is incorrect.

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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

The nurse administers amiodarone to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? (Select all that apply)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply)

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

Explanation

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