Health Promotion and Maintenance
53. A child recovering from abdominal surgery removes the nasogastric tube accidentally. A nurse replaces the nasogastric tube and places it to low wall suction. Two hours later, the nurse discovers that there is no drainage from the tube. What should be the nurse's first action?
. Ask the child to change position.
. Place an urgent call to the surgeon.
. Flush the tube with 10 mL of sterile water.
. Check the suction mechanism and settings.
Test-Taking Tip
Look for nursing actions that are the least invasive. Checking the suction settings can be done quickly and easily without disturbing the child.
Content Area: Child Health, Gastrointestinal; Integrated Process: Nursing Process, Evaluation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications of Diagnostic Tests/Treatments/Procedures
Health Promotion and Maintenance
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Answer 1 is incorrect because the nurse should first assess the suction. Although changing position may help move the tip of the tube from a potential blockage in the stomach, it is more effective to aspirate and irrigate the tube in this situation. Answer 2 is incorrect because the nurse should first assess the situation and attempt to resolve the issue before consulting the surgeon. Answer 3 is incorrect because the nurse should first assess the suction. If the suction is working properly, the nurse should check placement before instilling anything into the tube. Answer 4 is correct because the most likely cause of poor drainage is ineffective suction. The suction tubing may have become dislodged or the settings may have been altered. A nurse should inspect this first, then continue to problem-solve if needed.