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 C
Explanation
Choice A
Coffee is incorrect. Coffee can inhibit iron absorption and is not a good choice for increasing iron intake.
Choice B
Hot tea is incorrect. Similar to coffee, some compounds in tea can interfere with iron absorption, making it less optimal for increasing iron intake.
Choice C
Orange juice is correct. Orange juice is a great choice as it is high in vitamin C, which can enhance the absorption of iron from plant-based sources like oatmeal. The vitamin C in orange juice helps convert non-heme iron into a form that is more easily absorbed by the body.
Choice D
Apple juice is incorrect. While apple juice is a source of fluids, it doesn't provide the same level of vitamin C as orange juice, which is important for enhancing iron absorption.
Correct Answer is D
Explanation
Choice A
Offering water to the client hourly is not appropriate. While staying hydrated is important for overall health, offering water hourly might not be necessary unless there is a specific indication of dehydration. However, monitoring the client's fluid intake and output is a good approach.
Choice B
Reducing dairy product intake is not appropriate. Dairy product intake is not typically associated with sudden onset confusion. Reducing dairy product intake would not be the primary intervention for addressing confusion.
Choice C
Increasing daily sodium intake is not appropriate. Increasing sodium intake is unlikely to be the appropriate intervention for confusion unless there is a specific medical reason for it. Moreover, excessive sodium intake can have negative health consequences.
Choice D
Reviewing the intake and output record is appropriate. Confusion in an older client can be caused by various factors, including medical conditions, medication side effects, dehydration, and electrolyte imbalances. Reviewing the intake and output record (option D) is a reasonable intervention to gather more information about the client's fluid balance and hydration status. This can help the nurse assess whether the confusion might be related to dehydration or electrolyte imbalances.
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