Question

The nurse is caring for a client on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, the nurse should take which action?

1.Document the findings.
2.Reassess the pH in 4 hours.
3.Instill 30 mL of sterile water.
4.Administer a dose of a prescribed antacid.

Answer 1

The nurse should document the findings and report a gastric aspirate pH of 4.5 to the healthcare provider.

Step-by-step explanation:

A pH of 4.5 in the gastric aspirate indicates that the client has an acidic environment in their stomach. A pH of 4.5 is lower than the normal pH range of gastric acid, which is typically between 1.5 and 3.5. Therefore, the nurse should document the findings and report it to the healthcare provider. Instilling sterile water or administering an antacid is not indicated based on the pH level alone.