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An adult client with a nasogastric tube suddenly exhibits signs of respiratory distress, including coughing and difficulty breathing. What is the priority nursing intervention?
An adult client with a nasogastric tube suddenly exhibits signs of respiratory distress, including coughing and difficulty breathing. What is the priority nursing intervention?
- Immediately remove the nasogastric tube. (correct)
- Auscultate lung sounds for signs of aspiration.
- Reposition the client to a high-Fowler's position.
- Administer oxygen via nasal cannula at 2 L/min.
When confirming the placement of a nasogastric tube using pH testing, what pH value is considered desirable to indicate proper placement in the stomach?
When confirming the placement of a nasogastric tube using pH testing, what pH value is considered desirable to indicate proper placement in the stomach?
- Between 5.0 and 6.0
- Less than or equal to 5.5 (correct)
- Greater than 7.0
- Between 6.0 and 7.0
A client receiving continuous enteral feedings via nasogastric tube develops a distended abdomen and reports nausea. After confirming tube placement, which nursing intervention is most appropriate?
A client receiving continuous enteral feedings via nasogastric tube develops a distended abdomen and reports nausea. After confirming tube placement, which nursing intervention is most appropriate?
- Encourage the client to ambulate to promote gastric motility.
- Administer an antiemetic medication as prescribed.
- Decrease the rate of the enteral feeding.
- Aspirate the gastric contents to check for residual volume. (correct)
While providing routine care for a client with a nasogastric tube, the nurse notes that the tube is no longer secured to the client's nose. What is the most appropriate immediate action?
While providing routine care for a client with a nasogastric tube, the nurse notes that the tube is no longer secured to the client's nose. What is the most appropriate immediate action?
A nurse is preparing to administer medication through a client's nasogastric tube. Which action ensures the safety and patency of the tube?
A nurse is preparing to administer medication through a client's nasogastric tube. Which action ensures the safety and patency of the tube?
An older adult client with a nasogastric tube is at increased risk for which complication related to the tube’s presence?
An older adult client with a nasogastric tube is at increased risk for which complication related to the tube’s presence?
A nurse is providing oral hygiene to a client with a nasogastric tube. Why is this intervention important for this client population?
A nurse is providing oral hygiene to a client with a nasogastric tube. Why is this intervention important for this client population?
Which instruction is most important for the nurse to emphasize when educating a client and family regarding home care of a nasogastric tube?
Which instruction is most important for the nurse to emphasize when educating a client and family regarding home care of a nasogastric tube?
A nurse is caring for a client with a nasogastric tube connected to low intermittent suction. The client complains of a sore throat and dry mouth. Which intervention is most appropriate to provide comfort?
A nurse is caring for a client with a nasogastric tube connected to low intermittent suction. The client complains of a sore throat and dry mouth. Which intervention is most appropriate to provide comfort?
What is the primary rationale for verifying the placement of a nasogastric tube immediately after insertion and regularly thereafter?
What is the primary rationale for verifying the placement of a nasogastric tube immediately after insertion and regularly thereafter?
A nurse is caring for a client with a newly inserted nasogastric tube. What is the most reliable method to initially confirm proper placement immediately after insertion?
A nurse is caring for a client with a newly inserted nasogastric tube. What is the most reliable method to initially confirm proper placement immediately after insertion?
When caring for a client with a nasogastric tube, which finding requires the most immediate intervention?
When caring for a client with a nasogastric tube, which finding requires the most immediate intervention?
A client with a nasogastric tube is receiving intermittent bolus feedings. What nursing action is essential immediately before administering each feeding?
A client with a nasogastric tube is receiving intermittent bolus feedings. What nursing action is essential immediately before administering each feeding?
A nurse is preparing to administer medications via a nasogastric tube for a client who also receives continuous enteral feedings. Which action is most appropriate to ensure proper medication delivery and prevent interactions?
A nurse is preparing to administer medications via a nasogastric tube for a client who also receives continuous enteral feedings. Which action is most appropriate to ensure proper medication delivery and prevent interactions?
A nurse is caring for a client with a nasogastric tube attached to suction. The client reports persistent nausea. What should the nurse assess first?
A nurse is caring for a client with a nasogastric tube attached to suction. The client reports persistent nausea. What should the nurse assess first?
What documentation is most critical for a nurse to include after providing care and maintenance of a nasogastric tube?
What documentation is most critical for a nurse to include after providing care and maintenance of a nasogastric tube?
A client with a nasogastric tube develops excoriation around the nare. What nursing intervention is most appropriate to address this issue?
A client with a nasogastric tube develops excoriation around the nare. What nursing intervention is most appropriate to address this issue?
A client who is receiving enteral nutrition through a nasogastric tube begins to exhibit signs of fluid overload. Which nursing intervention is most important to implement?
A client who is receiving enteral nutrition through a nasogastric tube begins to exhibit signs of fluid overload. Which nursing intervention is most important to implement?
A nurse is caring for a client with a nasogastric tube. Prior to administering medication via the tube, the nurse aspirates 500 mL of gastric residual volume. What is the most appropriate nursing action?
A nurse is caring for a client with a nasogastric tube. Prior to administering medication via the tube, the nurse aspirates 500 mL of gastric residual volume. What is the most appropriate nursing action?
A client with a nasogastric tube complains of persistent nasal congestion and sinus pressure. Which intervention should the nurse implement to provide relief?
A client with a nasogastric tube complains of persistent nasal congestion and sinus pressure. Which intervention should the nurse implement to provide relief?
A client with a long-term nasogastric tube is at risk for developing which acid-base imbalance?
A client with a long-term nasogastric tube is at risk for developing which acid-base imbalance?
A client with a nasogastric tube requires frequent medication administration. Which consideration is most important to prevent tube occlusion when administering multiple medications?
A client with a nasogastric tube requires frequent medication administration. Which consideration is most important to prevent tube occlusion when administering multiple medications?
When evaluating the effectiveness of the care provided to a client with a nasogastric tube, which outcome indicates successful management?
When evaluating the effectiveness of the care provided to a client with a nasogastric tube, which outcome indicates successful management?
A client with a nasogastric tube develops persistent, non-productive coughing spells. What should the nurse do first?
A client with a nasogastric tube develops persistent, non-productive coughing spells. What should the nurse do first?
A client with a Salem Sump NG tube reports discomfort related to continuous suctioning. What is the priority intervention to alleviate this discomfort?
A client with a Salem Sump NG tube reports discomfort related to continuous suctioning. What is the priority intervention to alleviate this discomfort?
A nurse is caring for a client receiving continuous enteral feedings via NG tube. The nurse notes the client has developed diarrhea. What is the most appropriate initial nursing intervention?
A nurse is caring for a client receiving continuous enteral feedings via NG tube. The nurse notes the client has developed diarrhea. What is the most appropriate initial nursing intervention?
A nurse is providing education to a client being discharged home with a nasogastric tube for intermittent feedings. What is the most important instruction regarding medication administration?
A nurse is providing education to a client being discharged home with a nasogastric tube for intermittent feedings. What is the most important instruction regarding medication administration?
A nurse is reviewing the plan of care for a client with a nasogastric tube. Which task can be safely delegated to assistive personnel (AP)?
A nurse is reviewing the plan of care for a client with a nasogastric tube. Which task can be safely delegated to assistive personnel (AP)?
A client is receiving continuous enteral nutrition via a nasogastric tube. The nurse notes increasing abdominal distention and absent bowel sounds. What is the priority nursing intervention?
A client is receiving continuous enteral nutrition via a nasogastric tube. The nurse notes increasing abdominal distention and absent bowel sounds. What is the priority nursing intervention?
Which nursing action is most important to prevent aspiration pneumonia in a client receiving intermittent bolus feedings through a nasogastric tube?
Which nursing action is most important to prevent aspiration pneumonia in a client receiving intermittent bolus feedings through a nasogastric tube?
A client with a nasogastric tube begins to exhibit signs of hypokalemia. What assessment finding is most likely to be associated with this electrolyte imbalance?
A client with a nasogastric tube begins to exhibit signs of hypokalemia. What assessment finding is most likely to be associated with this electrolyte imbalance?
During routine care of a client with a nasogastric tube, the nurse finds that the tube has become clogged after medication administration. What is the appropriate first action to attempt to unclog the tube?
During routine care of a client with a nasogastric tube, the nurse finds that the tube has become clogged after medication administration. What is the appropriate first action to attempt to unclog the tube?
Flashcards
Nasogastric (NG) Tube
Nasogastric (NG) Tube
A flexible tube inserted through the nose into the stomach for removing contents or providing nutrition/medications.
NG Tube Care Includes
NG Tube Care Includes
Verifying placement, maintaining patency, assessing tolerance, evaluating skin integrity, providing oral care, and client education.
NG Tube Delegation
NG Tube Delegation
Assistive personnel cannot perform NG tube care and maintenance.
Check for Allergies
Check for Allergies
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Verify Client Identification
Verify Client Identification
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Use Standard Precautions
Use Standard Precautions
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Methods to Verify NG Tube Placement
Methods to Verify NG Tube Placement
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Purpose of Flushing NG Tube
Purpose of Flushing NG Tube
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Resecure NG Tube Properly
Resecure NG Tube Properly
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Provide Oral Care
Provide Oral Care
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Why review a client's medical records?
Why review a client's medical records?
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Why is privacy important?
Why is privacy important?
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Why is client education important?
Why is client education important?
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Signs of Alterations in Hydration
Signs of Alterations in Hydration
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Signs of Alterations in Skin Integrity
Signs of Alterations in Skin Integrity
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Dangers of color and pH checking.
Dangers of color and pH checking.
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How much sterile water needs to be inserted?
How much sterile water needs to be inserted?
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What does nausea mean?
What does nausea mean?
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Ensuring client safety..
Ensuring client safety..
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Client Consideration for Neonates
Client Consideration for Neonates
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Signs of Respiratory Distress
Signs of Respiratory Distress
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Importance of Documentation
Importance of Documentation
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Study Notes
- A nasogastric (NG) tube is a flexible, hollow tube inserted through the nose into the gastrointestinal (GI) system.
- NG tubes facilitate removal of liquid contents from the stomach or delivery of nutrition or medications.
- Maintaining an NG tube includes verifying placement, ensuring patency, assessing feeding tolerance, evaluating skin integrity around the nares, providing oral care, client teaching, and promoting safety and comfort.
- NG tube care and maintenance cannot be delegated to assistive personnel (AP).
Safety Considerations
- Determine if the client has allergies to prevent allergic reactions.
- Verify the client's identification before care 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.
- Equipment to verify NG tube placement includes:
- Irrigation set or syringe
- pH indicator
- Tongue blade
- Pen light
- Capnography equipment
- Radiographic confirmation is the most accurate method to determine placement.
- Bedside methods to confirm NG tube placement:
- Aspirate gastric contents and visually inspect.
- Test the pH of the aspirate (a pH ≤ 5.5 is preferable).
- Use a tongue blade and pen light to check for coiling in the throat.
- Use capnography to check for CO2 presence (CO2 indicates the tube is not in the stomach).
- Sterile water and an irrigation set are needed to flush the NG tube and ensure patency.
- Equipment to resecure the NG tube:
- Adhesive remover
- Benzoin or other skin preparation
- Adhesive-based nasoenteric holder or tape
- Hydrocolloid barrier to maintain skin integrity.
- Oral care and care of nares equipment:
- Oral care swabs or toothbrush and toothpaste
- Facial tissues
- Cotton swabs
- Lip balm
- Water-soluble lubricant
- An emesis basin aids in measuring gastric contents.
- A protective barrier (towel or waterproof pad) protects the area and the client’s gown.
Step-by-Step Procedure
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Step 1: Review the client’s medical record.
- Allergies
- Medical history
- Medications
- Previous vital sign data
- Pertinent laboratory values
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Step 2: Obtain supplies to ensure preparedness.
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Step 3: Provide privacy.
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Step 4: Introduce self to client to promote a therapeutic relationship.
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Step 5: Perform hand hygiene and apply PPE.
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Step 6: Identify the client using two identifiers.
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Step 7: Confirm the client’s allergy status.
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Step 8: Provide client education to decrease anxiety.
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Step 9: Evaluate the client for alterations in hydration or skin integrity.
- Hydration alteration indications: dry mucous membranes of the mouth, lips, and nares.
- Skin integrity alteration indications: redness, edema, irritation, drying, cracking, and chapping.
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Step 10: Verify NG tube placement:
- X-ray (post-insertion)
- Gastric aspiration
- pH testing
- Visual exam of oropharynx
- Testing for presence of CO2
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Step 11: Verify placement by checking the indelible mark on the tubing at the naris compared to previous documentation to see if tube has moved.
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Step 12: Ensure the NG tubing is taped to the gown on the upper chest to prevent skin breakdown caused by pressure on the naris or face.
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Step 13: Assess the characteristics, flow, and amount of drainage in the tubing and canister for signs that the NG tube has slipped into the small bowel or the lung.
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Step 14: Disconnect the tubing and aspirate the gastric contents.
- Check the color and pH of the secretions (pH should be ≤ 5.5) to ensure the NG tube is correctly placed.
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Step 15: Irrigate the NG tube with approximately 20 mL of air or irrigation solution via the drainage port to promote and confirm patency.
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Step 16: Ensure that the NG tube is free of kinks to maintain patency.
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Step 17: Assess the client for nausea, distended abdomen, or other indications that gastric decompression is needed, which can indicate that the NG tube has slipped into the duodenum or the presence of a GI complication.
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Step 18: Discuss findings with the client to decrease anxiety.
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Step 19: Ensure client safety before leaving the room:
- Place the call light within easy reach
- Lower the bed to the lowest position with brakes locked
- Place needed items (water, telephone, etc.) within easy reach.
Client Considerations
- Monitor neonates' oxygen levels frequently because their oxygen levels may be compromised and they are often nose breathers.
- Assess sutures are intact for clients who have recently had head or neck surgery because NG tubes may be sutured in place to prevent displacement.
Interventions for Unexpected Outcomes
- If the client shows signs of respiratory distress (coughing, gagging, difficulty breathing), the NG tube may be in the trachea and should be removed.
- If the NG tube is no longer secured properly, remove old adhesives and resecure the tube with new adhesives to prevent displacement.
- If unable to aspirate gastric contents, slightly advance the tubing and/or place the client on the left side. Repositioning can move the tubing into an area where gastric secretions can be aspirated.
Documentation
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Accurately document in the client’s medical record:
- Date and time of care
- Details of the care provided
- Description of aspirate
- Results of skin and mucous membrane assessment
- Client education provided
- Client’s response to NG tube care
- Unexpected outcomes and provider notification
- Nurse’ initials and signature
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