The nurse is inserting a small-bore nasogastric tube. Which action by the nurse is appropriate when completing this procedure?
1. Removing the stylet prior to inserting the tube into the client's nose
2. Measuring from the tip of the client's nose to the xiphoid process to determine length of tube to be inserted
3. Checking the nares for patency prior to passing the catheter
4. Applying sterile gloves before beginning the procedure
3
Rationale 1: The stylet should remain in place when passing a small-bore tube in order to provide some rigidity to the flexible catheter.
Rationale 2: The length of tube to be inserted is measured from the tip of the nose to the pinna and then to the xiphoid process.
Rationale 3: The nurse should check the nares for patency before passing the catheter, to check for any obstructions or irregularities.
Rationale 4: Sterile gloves are not required.
Global Rationale: The nurse should check the nares for patency before passing the catheter, to check for any obstructions or irregularities. The stylet should remain in place when passing a small-bore tube in order to provide some rigidity to the flexible catheter. The length of tube to be inserted is measured from the tip of the nose to the pinna and then to the xiphoid process. Sterile gloves are not required.
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