The nurse is inserting an NG feeding tube. Which step in the procedure is inaccurate, indicating further instruction is needed?
Perform hand hygiene and place patient in left lateral position. Determine length of tube from the xyphoid process to the tip of the patient's nose. Insert stylet into feeding tube. Inspect nares. Dip end of tube in ice water
Hand patient a cup of water with a straw. Gently insert the tube through the nostril to back of throat. Have patient flex head toward chest. Give small sips of water and advance the tube as patient swallows. Rotate tube 180 degrees while inserting.
When tip of tube reaches carina, stop and listen for air exchange from distal portion of tube. Continue to advance tube until desired length has been passed. Check back of throat with a penlight and tongue blade. Check placement of tube.
Mark exit site on tube with indelible ink. Apply tincture of benzoin to nose, and allow to become "tacky." Remove gloves and apply stabilization device. Obtain an X-ray to verify tube placement.
The Correct Answer is A
Rationale:
A. This option is inaccurate and indicates a need for further instruction. The patient should be placed in a high Fowler’s position, not left lateral, to facilitate passage and reduce aspiration risk. The tube should be measured from the tip of the nose → earlobe → xiphoid process, not just nose to xiphoid. Additionally, dipping the tube in ice water is not a recommended practice.
B. This describes correct technique: giving water to assist swallowing, flexing the head, and rotating the tube can ease insertion.
C. Listening for air exchange at the carina is outdated and unreliable for placement verification, but stopping advancement if resistance is met and checking placement afterward is still part of proper caution.
D. Marking the tube, securing it, and verifying placement with an X-ray are all appropriate and necessary steps.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Measuring to the mid-umbilicus is incorrect and would result in excessive tube length.
B. The correct method is to measure from the tip of the nose to the earlobe and then down to the xiphoid process. This ensures the NG tube reaches the stomach without unnecessary excess length.
C. The physician’s order typically specifies insertion of an NG tube, but not the length. Measurement is the nurse’s responsibility.
D. Selecting an “adult-size” tube does not determine insertion length; it only refers to the tube’s diameter.
Correct Answer is D
Explanation
Rationale:
A. Sepsis usually develops over time with signs such as fever, chills, and hypotension, not acute fluid-related symptoms.
B. Anaphylaxis presents with airway swelling, rash, hypotension, and wheezing rather than fluid overload symptoms.
C. Myocardial infarction may cause chest pain, diaphoresis, and ECG changes, not typically linked directly to IV infusion rate.
D. Circulatory overload is the most likely cause. Rapid infusion (200 mL/hr in an elderly patient) can overwhelm cardiac function, leading to dyspnea, cough, tachycardia, and signs of fluid overload.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.