A nurse is caring for a client who has a clogged NG tube. Which of the following actions should the nurse take?
Flush the NG tube using a push and pull technique.
Irrigate the NG tube witha carbonated beverage
Use a 1 mL syringe to flush the NG tube.
Place the patient in prone position.
The Correct Answer is A
Rationale
A. Flush the NG tube using a push and pull technique: The push-pull method helps dislodge debris or thick secretions by creating intermittent pressure changes within the tube. This technique is recommended to restore patency without causing excessive force that may damage the tube or gastric mucosa. It is the safest and most effective initial action for a clogged NG tube.
B. Irrigate the NG tube with a carbonated beverage: Carbonated beverages are not recommended because they can damage the tubing material and are ineffective at dissolving clogs. They may also introduce unwanted substances into the gastrointestinal tract. Current best practice favors warm sterile water rather than soda or acidic liquids.
C. Use a 1 mL syringe to flush the NG tube: A 1 mL syringe generates dangerously high pressure that could rupture the tube or injure gastric tissue. Large-volume syringes, typically 30–60 mL, are used to maintain safe, low pressure during flushing. Using a very small syringe creates risk without increasing the likelihood of clearing the obstruction.
D. Place the patient in prone position: Position changes do not clear mechanical obstructions in the NG tube and may compromise comfort or breathing. Safe NG tube management prioritizes flushing techniques rather than altering the client’s position. Changing posture will not resolve the cause of the clog and may delay appropriate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices
- Oxygen saturation: The client’s oxygen saturation dropped from 95% to 90% on 1 L/min nasal cannula, indicating potential hypoxemia. Immediate assessment and intervention are required to prevent respiratory compromise.
- Behavioral findings: The client’s agitation and verbal report of “I feel like something is wrong” signal a possible early change in condition. Behavioral changes can precede vital sign abnormalities and should be promptly evaluated alongside physiological measures.
Rationale for Incorrect Choices
- Pain: While pain is reported at a moderate level, it is expected postoperatively and does not explain the sudden change in oxygen saturation or agitation. Pain should be addressed after assessing potential acute complications.
- WBC count: A slightly elevated WBC may reflect postoperative inflammation or infection but is not the immediate priority in the context of acute hypoxemia.
- Bowel findings: Hypoactive bowel sounds are typical after abdominal surgery due to anesthesia and are not an urgent concern compared with declining oxygenation and agitation.
Correct Answer is D
Explanation
Rationale
A. Infection: Infection at an IV site usually presents with redness, warmth, pain, and possibly purulent drainage. Taut and edematous skin without these signs is more consistent with fluid leakage rather than infection.
B. Phlebitis: Phlebitis involves inflammation of the vein, often causing redness, warmth, swelling, and tenderness along the vein. Taut, edematous skin around the site without vein inflammation points to a different complication.
C. Air embolism: An air embolism presents with sudden respiratory distress, hypotension, and chest pain. Localized swelling at the IV site is not a typical manifestation of an air embolism.
D. Infiltration: Infiltration occurs when IV fluid leaks into the surrounding tissue, causing swelling, tautness, pallor, and cool skin around the insertion site. This complication matches the observed findings and requires prompt intervention to prevent tissue damage.
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