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?

Document that the nasogastric tube is in the correct place.

Notify the health care provider.

Check for placement by auscultating for air injected into the tube.

Retest the pH using another strip.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Documenting that the nasogastric tube is in the correct place is not appropriate in this scenario. A gastric pH of 7.35 is too high for stomach contents, which typically have a pH between 1.5 and 3.5. This high pH suggests that the tube may be misplaced, possibly in the respiratory tract or another non-gastric location. Therefore, documenting the tube as correctly placed could lead to serious complications if the tube is indeed misplaced.

Choice B Reason:

Notifying the health care provider is the most appropriate action. A pH of 7.35 is indicative of a potential misplacement of the nasogastric tube. The health care provider needs to be informed immediately to take corrective actions, such as ordering an X-ray to confirm the tube’s placement or re-evaluating the tube’s position. This step is crucial to ensure patient safety and prevent complications such as aspiration pneumonia or other adverse effects.

Choice C Reason:

Checking for placement by auscultating for air injected into the tube is an outdated and unreliable method. This technique can sometimes give false assurance of correct placement, as the sound of air can be heard even if the tube is in the respiratory tract. Current best practices recommend using pH testing and radiographic confirmation for accurate placement verification.

Choice D Reason:

Retesting the pH using another strip might seem like a reasonable step, but it is not the best immediate action. If the initial pH test shows a value of 7.35, it is unlikely that retesting will yield a significantly different result. The priority should be to notify the health care provider to address the potential misplacement promptly.

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Correct Answer is ["A","B","D","E"]

Explanation

Choice A Reason:

Aspirating the stomach contents is essential to ensure the nasogastric tube is correctly positioned in the stomach. This step helps verify that the tube has not migrated and is safe for medication administration. If the aspirate is not obtained, further steps should be taken to confirm the tube’s placement.

Choice B Reason:

Checking the residual volume is important to assess the stomach’s contents and ensure that the patient is tolerating the feedings or medications. High residual volumes may indicate delayed gastric emptying or other gastrointestinal issues. This information helps guide the timing and amount of medication administration.

Choice C Reason:

Removing the tube and placing it in the other nostril is not a standard practice before administering medication. This action is unnecessary and could cause discomfort or complications for the patient. The focus should be on verifying the tube’s placement and ensuring it is functioning correctly.

Choice D Reason:

Testing the stomach contents for a pH indicating acidity is a reliable method to confirm the nasogastric tube’s placement. Gastric contents typically have a pH of 1 to 5, indicating the tube is in the stomach. This step helps ensure the safe administration of medications.

Choice E Reason:

Turning off the suction to the nasogastric tube is necessary before administering medications. Suction can interfere with the absorption of the medication and may cause the medication to be removed from the stomach before it has a chance to take effect. Therefore, it is important to turn off the suction temporarily during medication administration.

A. Hemoptysis B. High-pitched holosystolic murmur C. Hepatomegaly

Correct Answer is A

Explanation

Choice A Reason:

Hemoptysis, or coughing up blood, is a common feature of both mitral valve stenosis and mitral valve regurgitation. In mitral valve stenosis, the narrowing of the valve leads to increased pressure in the pulmonary veins, which can cause pulmonary congestion and hemoptysis. Similarly, in mitral valve regurgitation, the backflow of blood into the left atrium increases pulmonary pressure, potentially leading to pulmonary edema and hemoptysis. Therefore, hemoptysis is a shared symptom of both conditions.

Choice B Reason:

A high-pitched holosystolic murmur is more commonly associated with mitral valve regurgitation rather than mitral valve stenosis. In mitral valve regurgitation, the murmur is caused by the backflow of blood from the left ventricle into the left atrium during systole3. Mitral valve stenosis, on the other hand, typically presents with a diastolic murmur due to the turbulent flow of blood through the narrowed valve during diastole. Therefore, a high-pitched holosystolic murmur is not a common feature of both disorders.

Choice C Reason:

Hepatomegaly, or an enlarged liver, can occur in advanced cases of both mitral valve stenosis and mitral valve regurgitation due to right-sided heart failure. However, it is not a primary or common feature of these conditions. Hepatomegaly is more often associated with conditions that directly affect the right side of the heart or cause systemic congestion. Therefore, hepatomegaly is not a common feature of both mitral valve stenosis and mitral valve regurgitation.

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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?

Nursing Test Bank

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Correct Answer is ["A","B","D","E"]

Explanation

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Correct Answer is A

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