35. What should be the first nursing action if an NG tube is not draining?
. Irrigate the tube.
. Reposition the client.
. Determine tube placement.
. Remove the tube and reinsert.
Test-Taking Tip
This is a priority question. More than one answer may be correct, but what does the nurse do first? Ask yourself, where is the tube tip?
Content Area: Adult Health, Gastrointestinal; Integrated Process: Nursing Process, Implementation; Cognitive Level: Comprehension; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
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Answer 1 is incorrect because placement should be determined by instilling air rapidly, not liquid. Once placement is confirmed, irrigation may be done. Answer 2 is incorrect because the concern is the placement of the tube first. Then, the position of the client may need to be assessed to determine if the position caused the tube to be dislodged. Answer 3 is correct because the lack of drainage may mean the tube is no longer in the correct location. Answer 4 is incorrect because placement should be determined before removal. Reinsertion may be distressful to the client.