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Checking for placement by auscultating for air injected into the tube is an outdated and unreliable method.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 D

Explanation

Choice A Reason:

A decreased thyroxine (T4) level is not expected in a client with Graves’ disease. Graves’ disease is an autoimmune disorder that leads to hyperthyroidism, where the thyroid gland produces excessive amounts of thyroid hormones, including T4. Therefore, the T4 level is typically elevated, not decreased.

Choice B Reason:

Similarly, a decreased triiodothyronine (T3) level is not expected in Graves’ disease. Like T4, T3 levels are usually elevated due to the overactive thyroid gland. T3 is the active form of thyroid hormone and is often increased in hyperthyroid conditions.

Choice C Reason:

Decreased thyroid-stimulating immunoglobulins (TSI) percentage is incorrect. In Graves’ disease, TSI levels are elevated because these antibodies stimulate the thyroid gland to produce more thyroid hormones. TSI mimics the action of TSH, leading to increased production of T3 and T4.

Choice D Reason:

Decreased thyroid-stimulating hormone (TSH) level is the correct answer. In Graves’ disease, the excessive thyroid hormones (T3 and T4) exert negative feedback on the pituitary gland, leading to suppressed TSH production. Therefore, TSH levels are typically low in patients with Graves’ disease.

A. Nonfat milk B. Apple C. Chocolate

Correct Answer is C

Explanation

Choice A Reason:

Nonfat milk is generally considered safe for individuals with GERD. While full-fat dairy products can exacerbate GERD symptoms due to their high-fat content, nonfat milk does not have this effect. It is low in fat and unlikely to trigger acid reflux. Therefore, nonfat milk is not a food that needs to be avoided by someone with GERD.

Choice B Reason:

Apples are typically safe for individuals with GERD. In fact, non-citrus fruits like apples are often recommended as part of a GERD-friendly diet. They are low in acid and unlikely to cause reflux symptoms. Therefore, apples do not need to be avoided by someone with GERD.

Choice C Reason:

Chocolate is a common trigger for GERD symptoms. It contains caffeine and theobromine, both of which can relax the lower esophageal sphincter (LES), allowing stomach acid to escape into the esophagus and cause reflux. Additionally, chocolate is high in fat, which can further exacerbate GERD symptoms. Therefore, it is advisable for individuals with GERD to avoid chocolate to prevent worsening of their symptoms.

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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?

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