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    Hesi Rn compass exit B proctored exam
    Select All That Apply

    A client is admitted for blunt force chest trauma following a motor vehicle collision. A nasogastric (NG) tube was inserted in the emergency department and chest x-ray results indicate that the tip of the NG tube is in the left chest. Which priority action(s) should the nurse implement? Select all that apply.

    Explanation & Rationale

    Rationale: A. Insert 30 mL air bolus while auscultating over abdomen: Introducing air into a misplaced NG tube in the chest cavity may worsen injury or cause a pneumothorax or tension pneumothorax, especially if the tube has entered the pleural space or lung. B. Remove the NG tube: Chest x-ray confirms malposition in the chest cavity, likely the pleural space or lung. The tube must be removed immediately to prevent further trauma or air/fluid accumulation. C. Clamp the NG tube: Clamping prevents the entry or exit of air and fluids, minimizing risk of complications like aspiration or worsening pneumothorax while awaiting removal or re-evaluation. D. Auscultate chest and abdomen following removal of NG tube: Assessing for abnormal breath or bowel sounds post-removal helps detect potential complications such as pneumothorax, hemothorax, or abdominal injury. E. Connect the NG tube to low wall suction: Connecting a malpositioned NG tube to suction could draw air or fluids from the pleural space or lung, worsening the trauma or leading to complications such as lung collapse.

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