The nurse inserts an NGT into a client who is disoriented. Which should the nurse implement for NGT insertion?
1. Ask for help with client restraint.
2. Contact provider about restraints.
3. Insert NGT without sips of water.
4. Administer a sedating medication.
1
1 and 2. To insert an NGT into a disoriented client, the nurse asks for help to restrain the client temporarily, if needed. The nurse does not need to collaborate with the provider for restraints, yet, because the client has not attempted to remove the tube and the nurse must implement noninvasive measures to avoid restraints, first.
3. The nurse provides sips of water during NGT insertion because the client may cooperate with the instructions. Sipping the water can facilitate the NGT passage for the client.
4. The nurse avoids administering a sedating medication because the client is dis-oriented already and the nurse does not want to aggravate the client's neurological status.
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