A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client reports anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?

Check to see if the suction equipment is working

Remove and reinsert the NG tube

Request a prescription for a medication to ease the client's anxiety

irrigate the NG tube with 100 mL of sterile water.

Answer and Explanation

The Correct Answer is A

A. Check to see if the suction equipment is working: According to the nursing process, the first step is assessment. The reported symptoms suggest that the NG tube may not be functioning, so checking the equipment should be done first.

B. Remove and reinsert the NG tube: This is invasive and not the first step. It should only be done if there's evidence of a problem that can't be fixed otherwise.

C. Request a prescription for a medication to ease the client's anxiety: This addresses the symptom but not the underlying cause (possible NG malfunction).

D. Irrigate the NG tube with 100 mL of sterile water: 100 mL is too much and could lead to aspiration. Also, this action comes after verifying equipment function.

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Correct Answer is A

Explanation

A. Alternate the client's liquids and food during meals: This helps clear the throat and prevent food accumulation, reducing the risk of aspiration.

B. Turn on the client's television during meals: Distractions should be minimized so the client can concentrate on safe swallowing.

C. Instruct the client to sit their head back while swallowing: This increases the risk of aspiration; instead, the chin-tuck method is often safer.

D. Elevate the client’s head of bed to 45° during meals: The head should be elevated to at least 90° during meals to reduce aspiration risk.

A. Position the head of the client's bed at 15° B. Change the feeding bag every 24 hr. C. Flush the tube with sterile sodium chloride solution every 4 hr. D. Check the gastric residual every 12 hr.

Correct Answer is B

Explanation

A. Position the head of the client's bed at 15°: The bed should be elevated at least 30° to 45° to prevent aspiration.

B. Change the feeding bag every 24 hr.: This prevents bacterial contamination, which can occur with prolonged use.

C. Flush the tube with sterile sodium chloride solution every 4 hr.: Tap water or sterile water (depending on the facility policy and client immunity status) is typically used; sodium chloride is not required unless otherwise ordered.

D. Check the gastric residual every 12 hr.: Gastric residuals should be checked every 4–6 hours in continuous feeding protocols.

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