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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A
Observing for abdominal distention is recommended. Gastric residual volume (GRV) is the amount of formula or food remaining in the stomach after a feeding through a gastric tube. A GRV of 325 mL is relatively high, and it's important to assess the client for signs of potential complications before contacting the healthcare provider. Observe for signs of abdominal distention, which could indicate that the stomach is not adequately emptying or that the feeding is not being tolerated well.
Choice B
Calculating 24-hour caloric intake is not recommended: While monitoring caloric intake is important for overall nutritional assessment, it does not address the immediate concern of a high GRV and the potential need for adjustment of the feeding rate or management.
Choice C
Measuring urinary output is not recommended: Urinary output is important to monitor for fluid balance, but it may not be directly related to the elevated GRV.
Choice D
Checking for body weight changes is not recommended: Monitoring body weight is essential for assessing nutritional status, but it may not provide immediate insights into the impact of the elevated GRV.
Correct Answer is C
Explanation
Choice A
Low residue diet is incorrect. A low residue diet is typically recommended for individuals with gastrointestinal conditions like inflammatory bowel disease or diverticulitis. This diet limits high-fibre foods to reduce bowel movements and ease digestive stress. However, it might not be the best option for a client with stomatitis who is struggling to eat due to mouth pain.
Choice B
Mechanical soft diet is incorrect. A mechanical soft diet includes foods that are soft and easy to chew, but they aren't necessarily pureed. While this diet might be more comfortable to eat for some individuals, a client with severe stomatitis might still experience pain while chewing. A pureed diet is a step further in terms of texture modification and can be better tolerated by someone with significant mouth pain.
Choice C
Pureed regular diet is correct. Stomatitis is inflammation of the mouth and can cause pain and discomfort, making it difficult for the client to eat. In this case, a pureed regular diet would be the most suitable choice.
Choice D
High protein soft diet is incorrect. While a high protein diet is important for recovery, healing, and maintaining muscle mass, the texture of the diet is equally important for someone with stomatitis. A high protein soft diet might still involve foods that are challenging to eat due to mouth pain, and therefore, a pureed diet would be a better option in this case.
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