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 B
Explanation
Choice A
24-hour food recall, food preferences, and allergies is incorrect. While these factors are important for understanding the client's dietary habits and possible dietary restrictions, they do not directly provide information about the client's current nutritional status or overall nutritional health.
Choice B
Body mass index (BMI) and serum albumin level is correct. Body mass index (BMI) and serum albumin level are commonly used parameters to assess a client's nutritional status. These measures provide valuable information about the client's weight, muscle mass, and protein status. Let's break down the options:
Choice C
Triceps skin fold and mid-arm circumference is incorrect. These measurements can provide information about the client's body composition and muscle mass. However, they are not as commonly used as BMI and serum albumin level for assessing nutritional status.
Choice D
Weight loss history and body surface area (BSA) is incorrect. Weight loss history is relevant for understanding changes in the client's weight over time, which can indicate potential malnutrition. However, it's not as comprehensive as BMI, which considers both weight and height. Body surface area (BSA) is not typically used to assess nutritional status.
Correct Answer is D
Explanation
Choice A
Planning low carbohydrate and high protein meals is not recommended. While meal planning is important for weight loss, focusing solely on low carbohydrate and high protein meals may not be the most balanced or sustainable approach. It's essential to consider a variety of nutrients and food groups in the diet.
Choice B
Engaging in strenuous activity for an hour daily is not recommended. Jumping into strenuous activity for an hour daily might not be realistic or safe for everyone, especially for someone who is just starting their weight loss journey. A more gradual increase in physical activity is often recommended.
Choice C
Participating in a group exercise class 3 times a week is not recommended. Group exercise classes can be beneficial, but they may not address the whole spectrum of weight loss factors. Additionally, starting with three times a week might be challenging for someone new to exercise.
Choice D
Keep a record of food and drinks consumed daily is recommended. When helping a client with a BMI of 30 (which falls within the obese range) start a weight loss plan, keeping a record of food and drinks consumed daily can be an effective initial approach. This approach is often referred to as "food journaling" or "food tracking." It involves writing down everything the client eats and drinks throughout the day. This practice can help raise awareness of eating habits, identify patterns, and uncover areas where changes can be made to reduce calorie intake.
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