The nurse is preparing to administer tube feedings through a client's new Salem sump nasogastric tube. The nurse is unable to withdraw any fluid from the tube before starting the feeding. Which is the priority action of the nurse?
a. Start the tube feeding as ordered and check the residual in 30 minutes.
b. Inject air into the nasogastric tube while auscultating the client's epigastric area.
c. Lower the head of the client's bed and attempt to aspirate fluid again.
d. Obtain orders for a chest x-ray to confirm placement before starting the feeding.
D
The nurse must verify tube placement before beginning any tube feeding or administering any medications through a tube. The most accurate way to determine placement is via chest x-ray. The nurse could cause the client to aspirate if she or he started the feeding then checked later for placement. Insufflation does not provide accurate results and should not be used to verify tube placement. The nurse must keep the client's head elevated at least 30 degrees.
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