ATI SM 3.0: Nasogastric tube

A nurse is performing a nasogastric intubation on a client and has reached the tubes predetermined length. Which of the following action should the nurse take first? A. Inspect the oropharynx with a penlight and a tongue blade. B. Obtain an x-ray examination of the chest and abdomen. C. Tape the tube securely in place with a tube holder device. D. Aspirate gastric contents.

A. Inspect the oropharynx with a penlight and a tongue blade. Rationale: First action nurse should take when using the airway, breathing, circulation approach to client care is inspect pt's oropharynx w/ a penlight & tongue blade to check for kinks & to ensure tube is not coiled in pt's airway. If this occurs, nurse should pull back on tube & try reinserting.

A nurse is caring for a client who has a newly inserted nasogastric tube. Which of the following actions should the nurse use to verify the initial placement of the tube? A. Obtain an x-ray. B. Auscultate injected air. C. Take a pH measurement of gastric aspirate. D. Identify the color of gastric contents

A. Obtain an x-ray. Rationale: The nurse should identify that obtaining an x-ray is most effective method to verify initial placement of a nasogastric tube.

A nurse is checking the client's nasogastric tube for placement. Which of the following procedures should the nurse implement? A. Instill 20 mL of air into the tube and listen for a whooshing sound. B. Aspirate stomach contents and check the pH. C. Aspirate stomach contents and check their color. D. Auscultate lung sounds.

B. Aspirate stomach contents and check the pH. Rationale: Checking the pH of stomach contents is recommended method for checking tube placement. The pH measurement of gastric aspirate is 4 or less. A pH measurement of gastric aspirate can be used to monitor placement after initial placement has been verified.

A nurse is caring for a client who is recovering from gastric surgery, is NPO, and has a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membranes? A. Allow the client to suck on ice chips. B. Provide frequent mouth care. C. Apply petroleum jelly to the client's naris. D. Offer throat lozenges for the client to use.

B. Provide frequent mouth care. Rationale: The nurse should perform frequent mouth care, such as brushing their teeth & providing oral swabs, to keep pt's mucous membranes from becoming dry & irritated.

A nurse is teaching a group of unit nurses about clients who have a need for gastric decompression. The nurse should identify that which of the following clients needs nasogastric tube intubation for gastric decompression? A. A 6-year-old child who ingested a toxic substance B. A 60-year-old client who has a gastrointestinal hemorrhage C. A 40-year-old client who has a postoperative bowel obstruction D. A 20-year-old client who has malabsorption syndrome

C. A 40-year-old client who has a postoperative bowel obstruction Rationale: A client who has a postoperative bowel obstruction should have a nasogastric tube inserted for decompression to remove gastric secretions. This will assist in relieving abdominal distention, nausea, & pain.

A nurse is informed during shift report that a pt has a nasogastric tube connected to continuous suction. The nurse should identify that this client must have which of the following types of tubes? A. Dobhoff tube B. Sengstaken-Blakemore tube C. Salem sump tube D. Ewald tube

C. Salem sump tube Rationale: Salem sump tube is used for continuous suction to decompress the stomach. The tube has two lumens; one tube removes gastric contents & other tube serves as air vent lets air enter stomach, allowing tube to float freely & preventing damage to gastric mucosa.

A nurse is caring for a client who has a nasogastric tube connected to suction. Which of the following findings indicates that the tube has become occluded? A. Active bowel sounds B. Passing flatus C. Increase in gastric secretions D. Increased abdominal distention

D. Increased abdominal distention Rationale: Tubes connected to suction decompress the gastrointestinal tract, which is needed when peristalsis is absent. If gastric secretions are unable to move through the gastrointestinal tract and if the nasogastric tube is unable to evacuate the stomach due to an occlusion, abdominal distention, nausea and, vomiting can occur.