Inserting/Removing a Nasogastric Tube

The nurse, removing a nasogastric (NG) tube from a client, flushes the NG tube prior to removing it. Which would be most appropriate for the nurse to do?

30-50 ml of air to flush out the tube or 10 ml of water or saline solution depending on hospital policy

What criteria would be used to determine whether or not the NG tube could be taken out?

Client's appetite returned, bowel sounds returned, also passing flatus

The health care provider has written a prescription for a client's nasogastric (NG) tube to be removed. Which would the nurse do first? Remove the tube from the client gown. Take off the adhesive tape from the client's nose. Separate the NG tube from the suction tubing. Discontinue the suction.

Discontinue to suction

In what position would the nurse place the client prior to removing a nasogastric tube?

In an upright position with the bedrail nearest the nurse down.

The nurse is preparing to insert a nasogastric (NG) tube into an adult client. Place the following steps in the correct order. Use all options. Direct the tube upward and backward along the floor of the nose. Measure the intended length to insert the NG tube. Advance the tube while the client swallows. Place the client in high Fowler's position. Lubricate the tube tip with water-soluble lubricant. Instruct the client to place the chin onto the chest.

Place the client in high Fowler's position. Measure the intended length to insert the NG tube. Lubricate the tube tip with water-soluble lubricant. Direct the tube upward and backward along the floor of the nose. Instruct the client to place the chin onto the chest. Advance the tube while the client swallows.

A client scheduled for the removal of a nasogastric tube asks the nurse, "Will taking out the tube hurt?" What is the nurse's best response? "Don't worry, I've done this procedure many times and no one has complained of pain." "We will numb your throat prior to removal so you will not experience any pain." "You may experience minor discomfort as the tube is being removed." "We will give you pain medication since tube removal causes moderate pain."

You may experience minor discomfort as the tube is being removed

The nurse has just confirmed proper placement of a nasogastric tube. Which action should the nurse take next?

apply skin barrier to the tip and end of the nose

Which would be most appropriate for the nurse to do when removing a nasogastric (NG) tube? Ask the client to turn the head to the side with the chin tilted up when pulling out tube. Ask the client to take short shallow breaths and pull out the tube slowly and carefully. Ask the client to take a deep breath and pull out the tube quickly and carefully. Ask the client to take a deep breath and pull out the tube slowly and carefully.

ask the client to take a deep breath and pull out the tube quickly and carefully

Following the removal of a nasogastric NG tube, the nurse should monitor the client for which possible adverse reaction?

gastric distention

A nurse is assessing a client who has recently had bowel surgery and will be receiving a nasogastric tube. Which finding would most likely contraindicate placement of a nasogastric (NG) tube by the nurse in this client? One nare being less patent than the other Abdominal distention Bleeding in the gastrointestinal tract History of facial fractures

history of facial fractures Rationale: Clients with facial fractures or facial surgeries present a higher risk for misplacement of the tube into the brain. Many institutions require a health care provider to place NG tubes in these clients, which would contraindicate the nurse placing the tube. The nurse should assess the patency of the client's nares by asking the client to occlude one nostril and breathe normally through the other. However, the nurse does this to select the nostril through which air passes more easily, not because one nare being less patent than the other is a contraindication for NG tube placement by the nurse. Abdominal distention does not contraindicate NG tube placement. Monitoring bleeding in the gastrointestinal (GI) tract is one of the indications for NG tube placement, so bleeding in the GI tract is not a contraindication.

Which documentation does the nurse complete after inserting a client's nasogastric (NG) tube? amount of time it took to complete the procedure client's vital signs and bowel sounds measurement of the exposed tube number of attempts to pass the tubing through the nostril

measurement of the exposed tube

The nurse has begun inserting the nasogastric (NG) tube when the client coughs. After assessing that the client can speak without difficulty, what does the nurse do next?

proceed with nasogastric tube placement

Following insertion of a nasogastric tube, the nurse needs to stabilize the tubing for the client. Which action is appropriate for the nurse to take? Attach the tubing to the bed linens with a rubber band and safety pin. Tape the tubing to the client's sleeve below shoulder level. Secure the tubing with a safety pin to the client's gown at shoulder level. Allow the tubing to hang freely to allow for freedom of movement.

secure the tubing with a safety pin to the client's gown at shoulder level

The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which has likely occurred?

the NG tube is in the client's airway

After putting on gloves, the nurse lubricates the nasogastric (NG) tube prior to insertion into the client's nares. Which lubricant is appropriate to use?

water soluble lubricant

After measuring from the client's nostril to the ear lobe, how does the nurse continue to measure the length of the nasogastric (NG) tube to be inserted for a client?

xiphoid process