The nurse is caring for four clients. Which client is suitable for NGT removal by the nurse?
1. Restless, confused, without bowel sounds
2. Difficulty swallowing from left-sided stroke
3. Not passing gas with complaints of anorexia
4. Abdomen slightly rounded with incisional pain
4
4. The client with a slightly rounded abdomen and incisional pain should have the NGT tube removed because a rounded abdomen does not carry the risks of distention and incisional pain is a factor that does not interfere with NGT removal. The nurse manages the client's pain with analgesic, keeping in mind that opioids usually lead to constipation.
1 and 2. The restless client and the client with dysphagia are at high risk for aspiration because the client potentially cannot protect the airway and needs the NGT to help prevent aspiration of gastric contents.
3. The client who is not passing gas and is experiencing anorexia is not a suitable candidate for NGT removal because lack of intestinal gas indicates peristaltic im-pairment. The anorexia is logical sequelae of impaired peristalsis because client's lose the appetite with gastric paresis.
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