The nurse prepares to insert a nasointestinal tube into a client. Which does the nurse implement for proper tube placement?
1. Measures from nose to earlobe to xiphoid process
2. Removes the guide wire after verifying placement
3. Places client on left side until verifying placement
4. Anchors the tube with tape after the tube insertion
2
2. The nurse maintains the guide wire in place until intestinal placement is verified because, once the guide wire is removed, it cannot be reinserted. If the tube needs repositioning, the nurse cannot manipulate it effectively.
1. The nurse measures from the tip of the nose to the earlobe to the xiphoid process and adds 20-30 cm for a proper length.
3. Positioning the client on the left or right side does not facilitate migration of the tube into the intestines.
4. The nurse anchors the nasointestinal tube in place after placement in the jejunum is verified.
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