A nurse is caring for an adult receiving enteral nutrition through a newly inserted small-bore nasogastric tube. For each finding or action, select the best classification.
Matrix
Choose your responses, then check the answer.
Explanation
A blindly placed short-term enteral tube requires radiographic confirmation before initial use. For ongoing care, the nurse documents and compares the external marking or length and uses institution-approved bedside verification methods; a change in length or new respiratory symptoms requires stopping the feeding and evaluating tube position and possible aspiration. Air insufflation with auscultation alone cannot reliably distinguish gastric from respiratory placement. Elevating the head of the bed during feeding and for the prescribed period afterward reduces aspiration risk unless contraindicated.
Correct Answer Confirm initial placement radiographically, track the external tube marking, elevate the head of the bed, and stop the feeding when displacement or aspiration cues appear. Do not rely on the air-bolus auscultation method alone.
Why It Fits Initial confirmation and ongoing displacement checks answer different safety questions. A previously confirmed tube can migrate, so the nurse compares the current external length and the client's respiratory response with the documented baseline.
Clinical Picture An increased external length suggests migration. New coughing, dyspnea, or desaturation during feeding can indicate airway compromise or aspiration and requires the feeding to stop while the client and tube position are evaluated.
Memory Link X-ray first use; mark and assess ongoing; stop for change.
NCLEX Rule Choose a verification method that can meaningfully reduce harm. A familiar but unreliable shortcut is not safer because it is fast.
Why the Alternatives Fail Air-bolus auscultation can sound similar when a tube is misplaced. Continuing a feeding after external-length change or respiratory symptoms exposes the client to aspiration and pulmonary injury.
Source
1ASPEN Safe Practices for Enteral Nutrition Therapy
2ASPEN Feeding Tube Placement Resources
Radiographic confirmation was documented before the tube's initial use. During later feedings, the nurse compares the external tube length with the recorded baseline, assesses respiratory tolerance, and follows the facility's approved verification procedure.
Initial Placement Confirmation — Radiographic confirmation is obtained and documented before the initial use of a blindly placed short-term enteral tube for feeding or medication administration.
External Tube Length — The tube marking or external length is documented at baseline and compared during ongoing care. A change can indicate migration and requires evaluation before use.
Air-Bolus Auscultation — Listening over the epigastrium while injecting air cannot reliably distinguish gastric from respiratory or esophageal placement and should not be used alone to verify tube position.