While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse implement?

Send fluid specimen to the lab.

Withdraw the NGT and reinsert.

Connect the NGT to wall suction.

Determine pH value of specimen.

Answer and Explanation

The Correct Answer is A

Choice A

Sending fluid specimen to the lab should be implemented. Cloudy green fluid aspirated from a nasogastric tube (NGT) can indicate that the tube is in the wrong place, likely in the respiratory tract (trachea) instead of the gastrointestinal tract (stomach). The green colour suggests the presence of bile, which is normally found in the stomach but not in the respiratory tract. This is a serious situation that requires immediate attention.

The most appropriate intervention in this case is to send the fluid specimen to the lab for analysis. This is important for confirmation of the content and to guide further steps. The nurse should also consult the healthcare provider to determine the appropriate course of action, which might involve removing and reinserting the NGT correctly.

Choice B

Withdrawing the NGT and reinsert should not be implemented. If the NGT is in the wrong place, reinserting it without further assessment could worsen the situation. The nurse should not reinsert the NGT until the correct placement is confirmed.

Choice C

Connecting the NGT to wall suction should not be implemented. Connecting the NGT to wall suction without verifying its placement could cause harm, especially if the tube is in the respiratory tract.

Choice D

Determine pH value of specimen should not be implemented. While assessing the pH of aspirated fluid can help confirm the location of the NGT, sending the specimen to the lab for analysis is a more comprehensive action in this situation, as it allows for more detailed examination and guidance for appropriate next steps.

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Correct Answer is B

Explanation

Choice A

Canned cream of mushroom soup, tuna salad, and water is inappropriate. Canned soups and processed foods like canned cream soups can be high in sodium. Tuna salad might also have added salt.

Choice B
B. Bacon, lettuce, and tomato sandwich, grapes, and skim milk is the appropriate selection. A serum sodium level of 155 mEq/L (155 mmol/L) is higher than the normal reference range (136 to 145 mEq/L or 136 to 145 mmol/L), indicating hypernatremia or high blood sodium levels. In this case, it's important for the client to choose foods that are lower in sodium to help manage their sodium intake.

Choice C

Taco salad, refried beans, low-fat ice cream, and coffee is inappropriate. Taco salad can contain salty ingredients, and refried beans can also be high in sodium. Processed meats and sauces used in tacos can contribute to sodium intake.

Choice D

Chicken salad on toast, fruit-flavoured yogurt, and iced tea is inappropriate. Chicken salad and some breads might contain added salt. Fruit-flavoured yogurts can also have added sugars, and iced tea can vary in sodium content depending on how it's prepared.

A. High protein. B. High roughage. C. Low cholesterol. D. Low salt.

Correct Answer is A

Explanation

Choice A

High protein should be encouraged. The small reddened area on the coccyx is concerning for a potential pressure ulcer (also known as a pressure sore or bed sore). Pressure ulcers can occur when there is prolonged pressure on a specific area of the skin, often in individuals who are bedridden or have limited mobility. Adequate nutrition, including a high protein diet, is essential for preventing and promoting the healing of pressure ulcers. Protein is crucial for tissue repair and wound healing. A diet high in protein can aid in the recovery of damaged skin and promote the healing process. It helps to maintain and rebuild skin tissue, which is particularly important when dealing with potential pressure ulcers.

Choice B

High roughage should not be encouraged. While dietary fibre (roughage) is important for overall bowel health and regularity, it may not have a direct impact on wound healing in this context.

Choice C

Low cholesterol should not be encouraged. A low cholesterol diet is typically recommended to manage cardiovascular health and reduce the risk of heart disease. While overall health is important, cholesterol levels may not have a direct impact on wound healing in this case.

Choice D

Low salt should not be encouraged. A low salt diet is often recommended for individuals with certain medical conditions, such as hypertension or heart failure. While maintaining a balanced diet is important, salt intake may not be the primary concern when addressing wound healing.

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While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has a serum sodium level of 155 mEq/L (155 mmol/L). The nurse should encourage the client to make which selection from the lunch menu? Reference Range Sodium [Reference Range: Adult 136 to 145 mEq/L or 136 to 145 mmol/L]

Correct Answer is B

Explanation

The nurse is conducting diet teaching for the family of an older client who has a small reddened area on the coccyx. Based on this finding, which diet should the nurse encourage for this client?

Correct Answer is A

Explanation

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