NG Tubes on the NCLEX
NG tube insertion, placement verification (pH and X-ray), care, and complications.
NG tubes show up on every exam. The verification question is the one students miss.
Insertion
Measure nose → earlobe → xiphoid process (NEX) and mark the tube. Position high Fowler's, head slightly forward. Lubricate with water-soluble gel. Advance to the nasopharynx, then have the patient tuck the chin and sip water through a straw while you advance with each swallow. Stop and pull back if the patient coughs, gags hard, or turns cyanotic: the tube may be in the airway.
Verifying placement
X-ray is the gold standard and is required before the first feeding or medication. Aspirate pH of 5 or less suggests gastric placement. Intestinal and respiratory aspirates run higher. Auscultating an air bolus (the whoosh test) is not reliable and is never acceptable alone. Air over the epigastrium can sound identical whether the tube sits in the stomach, esophagus, or lung. Recheck placement before each intermittent feeding and each med pass: external length at the nostril plus pH per policy.
Ongoing care
Keep the head of bed at 30 degrees or higher while the tube is in use. Provide oral and nasal care; a mouth-breathing NPO patient dries out fast. Secure the tube to the nose without pressure on the naris and re-tape when soiled. Flush with 30 mL water before and after feedings and meds. For tubes to suction: low intermittent suction for single-lumen (Levin), low continuous acceptable for double-lumen (Salem sump). Keep the blue pigtail above the stomach and never plug it.
Complications
Aspiration: the big one. Displaced tube plus feeding equals pneumonia. Hold the feeding and verify if the external length changed or the patient suddenly coughs or desaturates. Skin breakdown at the naris from tension on the tape. Electrolyte loss with prolonged suction: metabolic alkalosis, hypokalemia. Watch the BMP. If the tube comes out, do not blindly reinsert in a fresh surgical patient (esophageal or gastric surgery). Call the provider.
Frequently asked
Patient coughs violently during insertion?
Stop. Withdraw to the nasopharynx and let them recover. Coughing and cyanosis suggest tracheal placement.
Aspirate pH is 6. Feed?
No. Above 5 does not confirm gastric placement. Recheck per policy and get an X-ray if placement is in doubt.
Can the whoosh test ever verify placement?
No. It cannot distinguish stomach from lung. X-ray first, then pH plus external length for ongoing checks.
Quick check
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