Nursing Skill: Nasogastric Tube Insertion and Removal

The nurse in the skill video documented the following after inserting, then removing the nasogastric tube. Highlight the incorrect information the nurse documented. 04/01/YYYY 1425 ​Insertion: Client abdominal assessment: rigid abdomen, bowel sounds hypoactive, and last bowel movement was two days ago. Respiratory assessment WNL. Nasogastric tube inserted on client. Discussed procedure with client and client verbalized understanding. 6 French nasogastric tube inserted with no complications. Secured with tape. X-ray ordered, pending. 10mL of greenish-yellow gastric aspirate obtained and pH was noted to be 7.0. Client tolerated well. -------H. Harrison, RN ​ ​ 04/02/YYYY 1600 ​Removal: 6 French nasogastric tube removed without difficulty and was intact. Client tolerated well. Client verbalized understanding of all teaching. -------H. Harrison, RN ​ ​

6 French 7.0 6 French

When removing a nasogastric tube, the nurse should first instruct the client to hold their breath and then kink the tube and withdraw steadily. These actions _______ inadvertent aspiration of ______ and promote _____ comfort.

prevent gastric contents client

When preparing to insert a nasogastric (NG) tube for a client who had abdominal surgery, the nurse knows they must consult the healthcare provider before insertion if the client is currently experiencing or has a history of which conditions? Select all that apply.

Facial trauma Nosebleeds Basilar skull fracture

Upon assessment, you noted the following cues. Match each cue with the associated potential risk.

Client appears confused > Risk for difficult insertion of NG tube. Client has continuous cough > Risk for insertion into tracheobronchial tree. Client had nasal facial surgery 5 years ago > Risk of intracranial tube passage, which could cause neurological injury. Client is picking at tape on hand > Risk for inadvertent extubation and/or dislodgement of tube.

When reviewing the client chart, what additional information would you need to note to ensure safe nasogastric (NG) tube insertion? Select all that apply.

Client height and weight Client's medication list

What information should be recorded in the GI/GU portion of the I-SBAR's Assessment section? Select all that apply.

Client tolerated NG tube insertion well 10 French NG tube placed Client instructed to sip water throughout NG tube placement

Your assessment and chart review reveal the following assessment findings. Drag the assessment findings that require further follow-up prior to this skill being performed to the box on the right.

Frequent nosebleeds ​ Motorcycle crash with facial trauma Client has been on anticoagulants for 1 year

Review the nurse's notes below. After reviewing the nurses' notes, specify which assessment findings indicate the client has improved, there is no change, or the client has declined.

HR 92​ - no change Shortness of breath​ - declined O2 Saturation 93%​ - declined Pain 1/10​ - improved RR 24​ - declined

The client's NG tube was removed. The client continues to have decreased oxygen saturation and bilateral wheezes. In addition, the client has now developed a fever. From the list below, choose whether the potential interventions are indicated or contraindicated for this client.

Indicated: Notify the provider of the client assessment​ Request chest x-ray​ Prepare to suction client​ Contraindicated: Position client flat​

In the table below, choose which supplies are indicated or not indicated for the nasogastric (NG) tube insertion. ​

Indicated: ​Tongue blade​ pH reagent strips​ Cup of water ​ Not Indicated: 30 mL syringe Betadine Sterile gloves

Your client is on a continuous enteral feeding tube and appears confused. You suspect their nasogastric (NG) tube has been displaced. Which of the following nursing actions should be performed right away?

Perform Right Away​: Aspirate gastrointestinal contents and measure pH Remove displaced nasogastric tube and insert and verify placement of new tube ​ ​Yes ​If the tube has been displaced, these actions will need to be performed to ensure the client's enteral feedings can continue. ​ Obtain order for chest x-ray to rule out aspiration​ Not Immediately Necessary​: Obtain order for complete blood count​ Administer O2 at 10L nasal cannula ​ Remove displaced tube and do not replace ​ ​

Nurses using the xyphoid process to earlobe to nose (XEN) +10 method to approximate the distance from the nose to the stomach will measure the distance from the ______ to the _____ to the ______ and add ______.

The XEN +10 method measures the distance from the xyphoid process to earlobe to nose +10 centimeters.

After inserting the client's nasogastric tube and confirming its placement via x-ray, you have completed your scheduled assessment. Upon abdominal assessment, you note that the client's abdomen is distended, and the client is complaining of abdominal pain 4/10. When you perform a respiratory system assessment, you note dyspnea, cyanosis, a decrease in O2 saturation to 93%, and hear bilateral wheezes. Which one of the potential issues is most likely to contribute to this?

The nasogastric tube has been dislodged and may be in the respiratory tract.​

When removing a nasogastric (NG) tube, the nurse should first instruct the client to _____________ and then _________.

hold their breath kink the tube and withdraw steadily

While inserting an NG tube on your client, the client begins to cough as you are advancing the NG tube. This could indicate the tube has entered the ______. The nurse should _______ advancing the tube at this time to ensure client safety.

respiratory tract stop

The healthcare provider has ordered a nasogastric (NG) tube to be placed on a client with aspiration precautions. The nurse knows the client ________ be provided a cup of water and a straw to swallow during NG tube insertion, and the head of the bed should be kept at ____ degrees or above.

should not 30