A nurse is preparing to remove a nasogastric tube from a female client. The nurse should instruct the client to do which of the following just before the nurse removes the tube?
A. Exhale
B. Inhale and exhale quickly
C. Take and hold a deep breath
D. Perform a Valsalva maneuver
Correct Answer: C. Take and hold a deep breath.
When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep breath. This will close the epiglottis. This allows for easy withdrawal through the esophagus into the nose. The nurse removes the tube with one smooth, continuous pull.
Option A: The patient should take a deep breath, and hold it, not exhale. An NG tube should be removed if it is no longer required. The process of removal is usually very quick. Prior to removing an NG tube, verify physician orders. If the NG tube was ordered to remove gastric content, the physician’s order may state to “trial” clamping the tube for a number of hours to see if the patient tolerates its removal. During the trial, the patient should not experience any nausea, vomiting, or abdominal distension.
Option B: Inhaling and exhaling quickly could make the removal uncomfortable. Instruct the patient to take a deep breath and hold it. This prevents aspiration; holding the breath closes the glottis.
Option D: Performing the Valsalva maneuver is inappropriate. Kink the NG tube near the nares and gently pull out the tube in a swift, steady motion, wrapping it in hand as it is being pulled out. Dispose of the tube in a garbage bag.
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