Evolve HESI Practice Exam 2025 – All-in-One Resource to Master Your Nursing Exam Success!

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

Administer a dose of an antitussive

Clear the tube with 30 ml of air and check the pH of the fluid withdrawn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coughing, the best action for the nurse to take is to clear the tube with 30 ml of air and check the pH of the fluid withdrawn.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

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Discontinue the tube feeding for the day

Replace the nasogastric tube immediately

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