The nurse is assessing a patient with gastroesophageal reflux disease (GERD). Which finding would the nurse expect to observe? Select all that apply. One, some, or all responses may be correct.

Excessive salivation

Dyspepsia

Regurgitation

Blood-tinged sputum

Flatulence

Answer and Explanation

Correct Answer : B,C,E

Choice A Reason:

Excessive salivation, also known as water brash, can occur in some cases of GERD, but it is not one of the most common symptoms. Water brash happens when the body produces extra saliva to neutralize the acid in the esophagus. While it can be associated with GERD, it is not as prevalent as other symptoms like heartburn or regurgitation.

Choice B Reason:

Dyspepsia, or indigestion, is a common symptom of GERD. It includes discomfort or pain in the upper abdomen, bloating, and nausea. Dyspepsia occurs because the stomach acid irritates the lining of the esophagus and stomach, leading to these uncomfortable sensations. Therefore, dyspepsia is a typical finding in patients with GERD.

Choice C Reason:

Regurgitation is a hallmark symptom of GERD. It involves the backflow of stomach contents into the esophagus and sometimes into the mouth, causing a sour or bitter taste. This symptom is due to the weakening or relaxation of the lower esophageal sphincter, which allows stomach acid to escape into the esophagus.

Choice D Reason:

Blood-tinged sputum is not a common symptom of GERD. While severe cases of GERD can lead to complications such as esophagitis or esophageal ulcers, which might cause bleeding, this is not typical in most GERD cases. Blood-tinged sputum would warrant further investigation to rule out other conditions such as infections or malignancies.

Choice E Reason:

Flatulence, or excessive gas, can be associated with GERD. The digestive process can be affected by the reflux of stomach acid, leading to increased gas production and bloating. While not as prominent as dyspepsia or regurgitation, flatulence can still be a symptom experienced by patients with GERD.

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Correct Answer is B

Explanation

Choice A Reason:

Documenting that the nasogastric tube is in the correct place is not appropriate in this scenario. The normal pH range for gastric contents is typically between 1.5 and 3.5. A pH of 7.35 is much higher than this range, indicating that the tube may not be in the stomach. Therefore, documenting the tube as correctly placed could lead to potential complications, such as improper feeding or medication administration.

Choice B Reason:

Notifying the health care provider is the correct action. A pH of 7.35 suggests that the nasogastric tube may be misplaced, possibly in the respiratory tract or another non-gastric location. Immediate notification of the health care provider is crucial to prevent any adverse outcomes and to take corrective measures, such as confirming placement with an X-ray or re-inserting the tube.

Choice C Reason:

Checking for placement by auscultating for air injected into the tube is not a reliable method for verifying nasogastric tube placement. While this method was traditionally used, it has been found to be inaccurate and is no longer recommended. The sound of air entering the stomach can be misleading and does not confirm correct placement.

Choice D Reason:

Retesting the pH using another strip is not the best immediate action. While it is important to ensure the accuracy of the pH reading, a pH of 7.35 is significantly outside the normal gastric range, and retesting is unlikely to yield a different result. The priority should be to notify the health care provider to address the potential misplacement of the tube.

Correct Answer is ["31"]

Explanation

Let’s calculate the IV infusion rate step by step.

Step 1: Determine the total volume to be infused.

The total volume ordered is 1,000 mL.

Step 2: Determine the total time for the infusion.

The total time is 8 hours.

Step 3: Calculate the infusion rate in mL per hour.

Total volume (1,000 mL) ÷ Total time (8 hours) = 125 mL per hour.

Result: 125

Step 4: Determine the drop factor.

The IV tubing delivers 15 drops per milliliter.

Step 5: Calculate the infusion rate in drops per minute.

Infusion rate (125 mL per hour) × Drop factor (15 drops per mL) = 1,875 drops per hour.

Result: 1,875

Step 6: Convert the infusion rate to drops per minute.

Total drops per hour (1,875 drops) ÷ 60 minutes = 31.25 drops per minute.

Result: 31.25

Step 7: Round the result to the nearest whole number if necessary.

31.25 rounded to the nearest whole number is 31.

The nurse should run the IV infusion at a rate of 31 drops per minute.

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The nurse is assessing a patient with gastroesophageal reflux disease (GERD). Which finding would the nurse expect to observe? Select all that apply. One, some, or all responses may be correct.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35. Based on this information, which action should the nurse take at this time?

Correct Answer is B

Explanation

The doctor orders dextrose 5% in water 1,000 mL to be infused over 8 hours. The IV tubing delivers 15 drops per milliliter. The nurse in charge should run the IV infusion at a rate of: NOTE: Enter ONLY THE NUMBER DO NOT enter the unit of measurement

Correct Answer is ["31"]

Explanation

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