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
Following low carbohydrate diet with low glycaemic index foods is incorrect. This recommendation is not specifically related to the management of glomerulonephritis. While managing carbohydrate intake might be relevant for individuals with diabetes, it's not the primary focus for someone with kidney inflammation.
Choice B
Eating a high protein diet three times a day is incorrect: While protein is important for overall health and recovery, a high protein diet might not be the best recommendation for someone with compromised kidney function. Excessive protein intake could potentially put additional strain on the kidneys.
Choice C
Avoiding foods high in potassium is correct. Examples of foods high in potassium that the client should be cautious about include bananas, oranges, potatoes, tomatoes, spinach, and other fruits and vegetables. Glomerulonephritis is a condition involving inflammation of the glomeruli in the kidneys, which can affect kidney function and the regulation of electrolytes, including potassium. In glomerulonephritis, the kidneys might have difficulty filtering and excreting excess potassium, leading to a potential build-up of potassium in the blood (hyperkalaemia).
Choice D
Restricting sodium rich foods and excessive oral fluids is incorrect. This recommendation aligns more closely with managing fluid retention and blood pressure, which can be relevant for individuals with kidney issues. However, the primary concern in glomerulonephritis is often potassium balance, making the recommendation to avoid high potassium foods more pertinent.
Correct Answer is B
Explanation
Choice A
Protein is not essential. While protein can influence blood sugar levels to some extent, its effect is much smaller compared to carbohydrates. Protein is not typically counted as a primary factor in insulin dosing.
Choice B
Carbohydrates are essential. For a client with type 1 diabetes mellitus who uses both short-acting (mealtime) and long-acting (basal) insulin, counting carbohydrates is essential for meal planning and insulin dosing. Carbohydrates have the most direct and significant impact on blood sugar levels. When carbohydrates are consumed, they are broken down into glucose, which enters the bloodstream and can lead to increased blood sugar levels
Choice C
Dairy is not essential. Dairy products can contain carbohydrates (such as lactose), but the carbohydrate content varies and is not as significant as in foods like grains, fruits, and starchy vegetables.
Choice D
Fats are not essential. Fats have minimal direct impact on blood sugar levels. However, they can affect the overall rate of digestion and absorption of carbohydrates, potentially influencing the timing of insulin administration. But carbohydrate counting remains the primary focus for insulin adjustment.
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