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.

Answer and Explanation

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.

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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.

A. Sweaty palms. B. Bunions. C. Dry skin. D. Fatigue.

Correct Answer is D

Explanation

Choice A

Sweaty palms are incorrect. Sweaty palms could be a normal response to physical activity and might not necessarily indicate a significant underlying issue.

Choice B

Bunions are incorrect. While bunions can cause discomfort, they might not be directly related to overall health, especially in comparison to fatigue.

Choice C

Dry skin is incorrect. Dry skin could be related to various factors, including environmental conditions or skincare habits. While it's worth addressing, it might not be as immediately concerning as unexplained fatigue.

Choice D

Fatigue is correct. For a professional dancer, fatigue should be an issue that alerts the nurse to perform further assessment. While all of the options can provide information about the client's health, fatigue in a professional dancer could be indicative of various underlying issues that may affect their overall well-being and performance.

Fatigue in a dancer might result from factors such as inadequate nutrition, overtraining, insufficient rest, or underlying medical conditions. It's important for the nurse to explore further to understand the potential causes of the fatigue and address them appropriately.

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While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse implement?

Nursing Test Bank

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