NG tube fundamentals quiz 3

A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect? A. 6 B. 2 C. 10 D. 8

Correct Answer: B. 2 A pH of 2 is within the expected reference range of 0 to 4 for gastric secretions.

A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure? A. "Inhale forcefully during insertion." B. "Raise your index finger if you need to pause during the insertion." C. "Bear down during insertion." D. "Avoid making any swallowing motions during the insertion."

Correct Answer: B. "Raise your index finger if you need to pause during the insertion." The nurse should instruct the client that the insertion of an NG tube is uncomfortable and the gag reflex will be activated during the procedure. The nurse should establish a communication technique such as having the client raise a finger or hand to indicate distress and the need to pause the insertion process.

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the client's risk of aspiration? A. Irrigate the tubing with 30 mL of sterile water B. Elevate the head of the bed to 30° or 45° C. Suggest changing the feeding to lactose-free formula D. Warm the enteral formula to room temperature before feeding

Correct Answer: B. Elevate the head of the bed to 30° or 45° Elevating the head of the bed to at least 30° and preferably 45° helps prevent the gravitational reflux of gastric contents, thereby decreasing the risk of aspiration.

A nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse plan to take? A. Auscultate over the stomach while injecting air B. Request an X-ray of the client's abdomen C. Place the head of the client's bed in a flat position D. Administer the feeding if the pH of the aspirated contents is >6

Correct Answer: B. Request an X-ray of the client's abdomen The nurse should request an X-ray to verify the placement of the NG tube both after the initial insertion of the tube and if displacement of the tube is suspected. The nurse should verify NG tube placement prior to administering a bolus feeding.

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? A. Auscultate bowel sounds after each feeding B. Ensure the formula is cold before administering C. Elevate the head of the client's bed to 45° before the feeding D. Flush the tubing with 15 mL of water after the enteral feeding

Correct Answer: C. Elevate the head of the client's bed to 45° before the feeding The nurse should elevate the client's head of bed between 30° and 45° to prevent aspiration.

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? A. Give the client a glass of water B. Assist the client into a sitting position C. Explain the procedure to the client D. Measure the length of tubing to be inserted

Correct Answer: C. Explain the procedure to the client The nurse should apply the least invasive priority-setting framework when caring for this client, which assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections. Informing the client about the procedure reduces fear and assists in gaining the client's cooperation, which is important for NG tube insertion and is the priority nursing intervention.

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A. Maintain suction while removing the NG tube B. Instill 100 mL of air into the NG tube before removal C. Pinch the NG tube while removing the tube D. Instruct the client to breathe in and out during the removal of the NG tube

Correct Answer: C. Pinch the NG tube while removing the tube The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents.

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take? A. Deliver the formula at a slower rate B. Request a lower-fat formula C. Provide more water with feedings D. Instill a lactose-free formula

Correct Answer: C. Provide more water with feedings The elevation in the client's specific gravity indicates dehydration. The nurse should provide more fluids either by adding free water to feedings or by instilling water between feedings. Another strategy is to request a formula that contains less protein.

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? A. Remove the NG tube B. Advance the NG tube quickly C. Pull the NG tube back slightly D. Ask the client to tilt his head backward

Correct Answer: C. Pull the NG tube back slightly The nurse should slightly pull back the NG tube and instruct the client to breathe slowly. Once the client relaxes, the nurse should gently advance the tube as the client swallows.

A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take? A. Change the tube feeding bag every 48 hours B. Chill the formula prior to administration C. Increase the infusion rate D. Request a prescription for an isotonic enteral nutrition formula

Correct Answer: D. Request a prescription for an isotonic enteral nutrition formula The nurse should assist a client who develops diarrhea while receiving NG tube feedings by consulting with the provider and the dietitian regarding changing the client's formula to an isotonic formula. This formulation can be easier for the client to digest and can decrease diarrhea.

A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (Select all that apply.) A. Coat the tip of the tube with a water-soluble lubricant B. Ask the client to swallow water while the tube enters her throat C. Place the coiled tube in ice chips prior to insertion D. Tell the client to tilt her head backward as insertion begins E. Instruct the client to bear down during insertion

Correct Answers: A. Coat the tip of the tube with a water-soluble lubricant B. Ask the client to swallow water while the tube enters her throat D. Tell the client to tilt her head backward as insertion begins Lubricating the tube eases its passage. A water-based gel because will dissolve if the tube slips into the client's airway, while using petroleum jelly could cause respiratory problems. Swallowing water reduces the risk of gagging and aspiration and helps propel the tube down the esophagus. Hyperextending the neck reduces the curvature of the nasopharynx, which facilitates the insertion of the NG tube.

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Set the suction machine at 120 mmHg B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown E. Apply petroleum jelly to the client's nares

Correct Answers: B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown Frequent oral hygiene provides comfort for the client since mucous membranes become dry and uncomfortable when a client cannot drink fluids. Measuring the drainage at least every shift helps the provider calculate fluid loss and prescribe appropriate replacement therapy. An unsecured NG tube can irritate the nares if the tube is pulled or caught on the bed or other equipment. The tube can also be dislodged if not secured appropriately.

A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (Select all that apply.) A. Auscultate injected air B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid E. Check the aspirated fluid for glucose

Correct Answers: B. Verify the initial X-ray examination. C. Measure the length of the exposed tube. D. Determine the pH of aspirated fluid. The nurse should confirm the NG tube placement by checking the X-ray results following the insertion of the NG tube. In addition, the nurse should check the length of the NG tube that is exposed by comparing the markings on the tube to the client's nose to verify tube placement. Finally, the nurse should check the pH of aspirated fluid to verify the tube placement.