After 2 days of administering the client's continuous nasogastric tube (NGT) feeding at 35 ml/hr successfully, the nurse aspirates 150 ml of formula. Which should the nurse implement first?
1. Discard aspirate and continue with the feeding.
2. Flush tube with 30 ml of normal saline solution.
3. Return aspirate and re-evaluate client in 1 hour.
4. Collaborate about the aspirate with the provider.
1
1. This is the first time the nurse aspirates an excessive volume of fluid from the client's NGT, so the nurse discards the 150-ml aspirate, documents the event, and communicates the finding to next nurse. If on several occasions the nurse aspirates more than 150 ml, the nurse notifies the provider; however, excessive NGT aspirate warrants further investigation by the nurse at that time and requires the nurse to as-sess the client carefully on restarting the feeding.
2. The nurse flushes the NGT after discarding the excessive NGT aspirate to maintain tube patency.
3. The nurse returns the aspirate if the volume is less than 100 ml.
4. The nurse avoids collaborating with the provider at this point unless client assess-ment data indicates a potential complication.
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