The nurse is feeding a confused client via a small-bore nasoenteric tube. The nurse observes the client pulling at the tube and then notices an increase in external tube length from the original exit mark. After immediately stopping the feeding, which action is appropriate for the nurse to take next? A)Advance the tube to the original exit mark, check gastric aspirate pH, and resume feeding B)Contact the health care provider to request a prescription for hand mitts C)Contact the health care provider to request an x-ray to verify tube placement D)Reinsert the guide wire and advance the tube to its original exit mark

Question

Quizplus · Accepted Answer

11ecbb05_cb7d_9bd6_b433_7dca919f87d6_MD0009_00 A nasoenteric feeding tube is used for administration of continual or intermittent enteral feedings and medications. The tube is marked at the exit site (nare) with indelible ink during the initial placement x-ray. The tube may have moved out of the correct position if its external length changes. If this occurs, the nurse should contact the health care provider (HCP) and request a prescription for a repeat x-ray to determine tube location. Based on the x-ray results, enteral feeding may be resumed or the HCP may prescribe insertion of a new tube according to institution policy (Option C). (Option A) Even if bedside methods to determine placement are used (eg, gastric aspirate pH and appearance), advancing the tube to the original marking does not guarantee correct placement; these methods are not accurate indicators. Tube feedings should not be resumed after tube dislodgment without x-ray verification of correct placement. (Option B) A prescription for hand mitts to keep a confused client from disrupting enteral nutrition may be appropriate if other less restrictive interventions (eg, keeping tubing out of client's sight, one-on-one sitter) are ineffective or unavailable. However, this should not be the nurse's next action. (Option D) The guide wire (stylet) is secured before tube insertion and remains in place until placement is verified by x-ray. Once removed, the guide wire should never be reinserted while the tube is in place as it can protrude and damage both the tube and the client's mucosa. Educational objective: A feeding tube is marked with indelible ink at the exit site (nare). If the external length of the tube changes, the nurse should contact the health care provider and request a prescription for a repeat x-ray to determine tube location before resuming administration of enteral feedings and medications.

The Nurse Is Feeding a Confused Client Via a Small-Bore