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Questions and Answers
A patient with a nasogastric tube is prescribed to have it removed. Which healthcare provider can the registered nurse (RN) delegate this task to?
A patient with a nasogastric tube is prescribed to have it removed. Which healthcare provider can the registered nurse (RN) delegate this task to?
- A new graduate Registered Nurse (RN)
- A practical nurse (PN) (correct)
- A medical student
- Assistive personnel (AP)
Prior to removing a nasogastric tube, why is it important for the nurse to review the client's medical record?
Prior to removing a nasogastric tube, why is it important for the nurse to review the client's medical record?
- To assess the client's understanding of their medication regimen.
- To confirm the client's preferred method of tube removal
- To identify any allergies or conditions that may affect the removal process. (correct)
- To determine the client's insurance coverage for the procedure.
Before initiating the removal of a nasogastric tube, which action should the nurse prioritize to ensure client safety?
Before initiating the removal of a nasogastric tube, which action should the nurse prioritize to ensure client safety?
- Verifying the provider's order for tube removal. (correct)
- Administering a pain medication to minimize discomfort.
- Ensuring the client has signed a consent form for the removal.
- Consulting with a dietitian regarding the client's nutritional needs.
What is the primary rationale for placing a client in high-Fowler's position before removing a nasogastric tube?
What is the primary rationale for placing a client in high-Fowler's position before removing a nasogastric tube?
Why is it important to disconnect the nasogastric tube from suction or feeding prior to its removal?
Why is it important to disconnect the nasogastric tube from suction or feeding prior to its removal?
What action should the nurse instruct the client to perform as the nasogastric tube is being removed?
What action should the nurse instruct the client to perform as the nasogastric tube is being removed?
If resistance is encountered while removing a nasogastric tube, what is the most appropriate nursing action?
If resistance is encountered while removing a nasogastric tube, what is the most appropriate nursing action?
Following removal of a nasogastric tube, for what primary complication should the nurse assess the client?
Following removal of a nasogastric tube, for what primary complication should the nurse assess the client?
A nurse is preparing to remove a nasogastric tube. What is the purpose of flushing the tube with water or air prior to removal?
A nurse is preparing to remove a nasogastric tube. What is the purpose of flushing the tube with water or air prior to removal?
What information should the nurse include in the documentation after removing a nasogastric tube?
What information should the nurse include in the documentation after removing a nasogastric tube?
A nurse is preparing to remove a nasogastric tube from a client. Which assessment finding would necessitate delaying the removal and contacting the provider?
A nurse is preparing to remove a nasogastric tube from a client. Which assessment finding would necessitate delaying the removal and contacting the provider?
When removing a nasogastric tube, why is it important for the nurse to clamp and kink the tube near the client's nose?
When removing a nasogastric tube, why is it important for the nurse to clamp and kink the tube near the client's nose?
After removing a nasogastric tube, the nurse cleans adhesive residue from the client's face and provides oral hygiene. What is the primary rationale for these actions?
After removing a nasogastric tube, the nurse cleans adhesive residue from the client's face and provides oral hygiene. What is the primary rationale for these actions?
A nurse is teaching a practical nurse (PN) about removing a nasogastric tube. Which instruction is most important to emphasize regarding potential complications during the procedure?
A nurse is teaching a practical nurse (PN) about removing a nasogastric tube. Which instruction is most important to emphasize regarding potential complications during the procedure?
When reviewing a client's medical record prior to nasogastric tube removal, what specific information is most important for the nurse to identify to prevent complications?
When reviewing a client's medical record prior to nasogastric tube removal, what specific information is most important for the nurse to identify to prevent complications?
A nurse is preparing to remove a nasogastric tube that was used for gastric decompression. What action should the nurse take regarding the gastric output in the collection container?
A nurse is preparing to remove a nasogastric tube that was used for gastric decompression. What action should the nurse take regarding the gastric output in the collection container?
What is the primary purpose of instructing a client to hold their breath during the removal of a nasogastric tube?
What is the primary purpose of instructing a client to hold their breath during the removal of a nasogastric tube?
A client becomes cyanotic and begins coughing immediately after nasogastric tube removal. What is the nurse's immediate priority?
A client becomes cyanotic and begins coughing immediately after nasogastric tube removal. What is the nurse's immediate priority?
A nurse is removing a nasogastric tube. Which action demonstrates proper technique to minimize trauma to the client?
A nurse is removing a nasogastric tube. Which action demonstrates proper technique to minimize trauma to the client?
After removing a nasogastric tube, the nurse assesses the client's nares and skin around the nose. What is the nurse primarily assessing for?
After removing a nasogastric tube, the nurse assesses the client's nares and skin around the nose. What is the nurse primarily assessing for?
To ensure client safety, the nurse performs several actions before leaving the room after nasogastric tube removal. Which action is the MOST important?
To ensure client safety, the nurse performs several actions before leaving the room after nasogastric tube removal. Which action is the MOST important?
A nurse is preparing to remove a nasogastric tube from a client following abdominal surgery. What specific assessment finding would require the nurse to collaborate with the provider before removing the tube?
A nurse is preparing to remove a nasogastric tube from a client following abdominal surgery. What specific assessment finding would require the nurse to collaborate with the provider before removing the tube?
Before removing a nasogastric tube, the nurse plans to flush the tube with 10 mL of water. Which outcome indicates that the flushing was successful?
Before removing a nasogastric tube, the nurse plans to flush the tube with 10 mL of water. Which outcome indicates that the flushing was successful?
A nurse is removing a nasogastric tube. Which action should the nurse perform immediately after removing the tube from the nares?
A nurse is removing a nasogastric tube. Which action should the nurse perform immediately after removing the tube from the nares?
A nurse is educating a client on what to expect during removal of a nasogastric tube. Which statement by the nurse is most appropriate?
A nurse is educating a client on what to expect during removal of a nasogastric tube. Which statement by the nurse is most appropriate?
A nurse is reviewing the steps for nasogastric tube removal with a newly hired practical nurse (PN). Which step, if performed by the PN, requires intervention by the supervising RN?
A nurse is reviewing the steps for nasogastric tube removal with a newly hired practical nurse (PN). Which step, if performed by the PN, requires intervention by the supervising RN?
A client reports a burning sensation and increased nasal congestion following removal of a nasogastric tube. Which intervention should the nurse implement first?
A client reports a burning sensation and increased nasal congestion following removal of a nasogastric tube. Which intervention should the nurse implement first?
Which action during nasogastric tube removal increases the risk of infection transmission?
Which action during nasogastric tube removal increases the risk of infection transmission?
What is the primary purpose of checking that the tip of the nasogastric tube is intact after removal?
What is the primary purpose of checking that the tip of the nasogastric tube is intact after removal?
The nurse is removing a nasogastric tube from an elderly client. Which modification to the standard procedure is most appropriate for this client?
The nurse is removing a nasogastric tube from an elderly client. Which modification to the standard procedure is most appropriate for this client?
After nasogastric tube removal, a client reports increased abdominal distention and nausea. Which action should the nurse take first?
After nasogastric tube removal, a client reports increased abdominal distention and nausea. Which action should the nurse take first?
A newly licensed nurse is observing an experienced nurse remove a nasogastric tube. Which statement made by the newly licensed nurse indicates a need for further teaching?
A newly licensed nurse is observing an experienced nurse remove a nasogastric tube. Which statement made by the newly licensed nurse indicates a need for further teaching?
What nursing action is most important when ensuring client safety immediately after a nasogastric tube is removed?
What nursing action is most important when ensuring client safety immediately after a nasogastric tube is removed?
Which rationale supports the removal of gloves and application of a new pair after nasogastric tube removal but before cleaning the client’s face?
Which rationale supports the removal of gloves and application of a new pair after nasogastric tube removal but before cleaning the client’s face?
Flashcards
NG or NI Tube Purpose
NG or NI Tube Purpose
Inserted to decompress the stomach or administer nutrition/medications.
Delegation of NG/NI Removal
Delegation of NG/NI Removal
A nurse can remove NG/NI tubes if prescribed, but AP cannot.
Check for Allergies
Check for Allergies
To prevent allergic reactions during the procedure.
Verify Client Identification
Verify Client Identification
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Use Standard Precautions
Use Standard Precautions
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Use Disposable Pad
Use Disposable Pad
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Provide Tissues
Provide Tissues
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50-mL Syringe Use
50-mL Syringe Use
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Plastic Disposable Bag
Plastic Disposable Bag
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Review Medical Record
Review Medical Record
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Obtain Supplies
Obtain Supplies
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Provide Privacy
Provide Privacy
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Introduce Yourself
Introduce Yourself
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Hand Hygiene
Hand Hygiene
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Two Unique Identifiers
Two Unique Identifiers
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Confirm Allergy Status
Confirm Allergy Status
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Client Education
Client Education
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Evaluate Indications to Delay
Evaluate Indications to Delay
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High Fowler's Position
High Fowler's Position
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Place Disposable Pad
Place Disposable Pad
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Offer Emesis Basin/Tissues
Offer Emesis Basin/Tissues
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Don Clean Gloves
Don Clean Gloves
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Disconnect Suction/Feedings
Disconnect Suction/Feedings
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Detach Tube from Gown
Detach Tube from Gown
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Remove Nose Tape
Remove Nose Tape
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Flush the Tube
Flush the Tube
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Clamp the Tube
Clamp the Tube
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Deep Breath and Hold
Deep Breath and Hold
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Smoothly Pull the Tube
Smoothly Pull the Tube
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Check Tube Tip Intact
Check Tube Tip Intact
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Measure Output (If Applicable)
Measure Output (If Applicable)
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Dispose of Equipment
Dispose of Equipment
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Clean Face/Nares
Clean Face/Nares
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Assess Skin Integrity
Assess Skin Integrity
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Ensure Client Safety
Ensure Client Safety
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Study Notes
- Nasogastric (NG) or nasointestinal (NI) tubes are inserted to decompress the stomach or administer nutrition/medications.
- A registered nurse (RN) can delegate the removal of an NG or NI tube to a practical nurse (PN), but not to assistive personnel (AP).
Safety Considerations
- Determine if the client has allergies to prevent allergic reactions.
- Verify client identification to ensure the correct procedure is performed on the correct client.
- Use standard and infection control precautions to prevent the transmission of infectious organisms.
Equipment
- Nonsterile gloves and other personal protective equipment (PPE) are needed based on standard precautions.
- A disposable pad or towel is used to collect any spillage of secretions.
- Tissues are provided for the client to wipe their nose and mouth.
- A 50-mL syringe is needed to flush the tube or instill air prior to removal.
- A plastic disposable bag is required for disposal of the tube and suction equipment.
Step-by-Step Procedure
- Step 1: Review the client’s medical record for allergies, medical history, medications, vital signs, lab values, and the provider’s order.
- Step 2: Gather all necessary supplies.
- Step 3: Provide privacy to maintain client confidentiality.
- Step 4: Introduce yourself to the client to promote a therapeutic relationship.
- Step 5: Perform hand hygiene and put on PPE if indicated.
- Step 6: Identify the client using two unique identifiers.
- Step 7: Confirm the client’s allergy status.
- Step 8: Educate the client about the procedure to reduce anxiety.
- Inform the client about potential throat discomfort.
- Ask the client to hold their breath during removal.
- Step 9: Evaluate the client for contraindications, such as inability to tolerate oral intake, absent bowel sounds/gag reflex, or surgical sutures near the nose/stomach.
- Delay removal and consult the provider if contraindications are present.
- Step 10: Place the client in high-Fowler’s position (30° to 45°) to reduce aspiration risk.
- Step 11: Place a towel or disposable pad across the client’s chest to protect clothing and linens.
- Step 12: Offer tissues and an emesis basin.
- Step 13: Put on clean gloves.
- Step 14: Disconnect the NG tube from wall suction or feeding infusion tubing, if present.
- Step 15: Detach the NG or NI tube from the gown.
- Step 16: Remove the tape or tube holder from the client’s nose.
- Step 17: Flush the tube with 10 mL of water/saline or instill 30-50 mL of air to clear contents and reduce aspiration risk.
- Step 18: Clamp the tube and kink it near the nose to prevent leakage.
- Step 19: Instruct the client to take and hold a deep breath to close the epiglottis.
- Step 20: Smoothly and steadily pull the tube out while collecting it in a towel or pad.
- Stop immediately and notify the provider if resistance is met.
- Step 21: Check that the tip of the tube is intact to ensure no part remains in the client.
- Step 22: Measure and record the output in the collection container if the tube was used for decompression.
- Step 23: Dispose of the NG/NI tube and equipment per facility policy.
- Step 24: Remove dirty gloves and apply clean gloves.
- Step 25: Clean adhesive residue, the nares, and provide oral hygiene.
- Step 26: Assess skin integrity under the tube holder/tape and at the nares.
- Step 27: Discuss findings with the client.
- Step 28: Ensure client safety before leaving the room, with call light and needed items within reach.
Interventions for Unexpected Outcomes
- Assess respiratory status for aspiration signs: cyanosis, coughing, or fever.
- Stop immediately if resistance is felt during removal and notify the provider to avoid trauma.
Documentation
- Document the date of removal, GI assessment findings, skin integrity, client response, and drainage measurement.
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Description
Learn about the safe removal of nasogastric (NG) and nasointestinal (NI) tubes, including necessary equipment, safety considerations, and the delegation of tasks to practical nurses. This covers allergies, client identification, infection control, and proper disposal of equipment.