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? (Select all that apply.)
1. Flush the tube.
2. Return aspirate.
3. Discard aspirate.
4. Assess the client.
5. Resume feeding.
6. Convey findings.
1, 3, 4, 5, 6
1, 3, 4, 5, and 6. 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, although the nurse does not need to notify the provider at this point, excessive NGT aspirate war-rants further investigation by the nurse at this time and requires the nurse to assess the client carefully before restarting the feeding.
2. The nurse returns the aspirate if the volume is less than 100 ml.
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