Evolve HESI Practice Exam

A client receiving nasogastric tube feedings reports severe coughing. What is the best action for the nurse to take?

1. Administer a dose of an antitussive

2. Clear the tube with 30 ml of air and check the pH of the fluid withdrawn

3. Discontinue the tube feeding for the day

4. Replace the nasogastric tube immediately

The correct answer is: Clear the tube with 30 ml of air and check the pH of the fluid withdrawn

When a client receiving nasogastric tube feedings reports severe coughing, the best action for the nurse to take is to clear the tube with 30 ml of air and check the pH of the fluid withdrawn. This approach allows the nurse to assess whether the tube is properly positioned in the stomach. Severe coughing could indicate that the feeding is inappropriately administered, potentially entering the airway rather than the esophagus. By clearing the tube with air, the nurse can ensure that it is not obstructed and that gastric contents can be aspirated effectively for a pH check. Checking the pH is crucial because it helps to confirm the placement of the nasogastric tube. A pH of 0-4 indicates gastric placement, while a pH of 6 or higher suggests that the tube may be in the intestines or respiratory tract, which requires immediate attention. This method prioritizes patient safety by enabling further assessment of the situation before deciding on the next steps or interventions. Other options, while they may seem reasonable, do not address the immediate concern of verifying proper tube placement. Administering an antitussive might suppress the cough reflex without resolving the underlying issue. Discontinuing the feeding might not be necessary if the