A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

. Combine the medications with the formula in the feeding bag:

Combining medications with the enteral feeding formula in the feeding bag is not recommended as it may alter the medication's efficacy or stability. Additionally, mixing medications with the feeding formula could result in interactions between the medications or between the medications and the formula components.

B. Dilute each crushed medication with warm water:

While diluting crushed medications with warm water may facilitate administration through the NG tube, it is not always necessary or appropriate for all medications. Dilution should be done according to specific medication guidelines or manufacturer recommendations. Some medications may not require dilution, while others may require a specific diluent or method of administration.

C. Flush the NG tube with 5 mL of sterile water for irrigation prior to administration.

Flushing the NG tube with 30-60ml sterile water for irrigation before administering medications helps ensure that the tube is clear of any residual feeding formula or medication residue. This step helps prevent potential clogging of the tube and ensures that the medications are delivered effectively to the client's stomach or intestines.

D. Mix the medications together in a single syringe:

Mixing medications together in a single syringe may increase the risk of drug interactions or chemical incompatibilities between the medications. Each medication should be administered separately to ensure accurate dosing and prevent potential interactions. Administering medications separately also allows for better monitoring of the client's response to each medication.

A. Apply the pouch while the skin barrier is still damp.

Applying the pouch while the skin barrier is damp can lead to poor adhesion and potential leaks. It’s essential to ensure the skin is completely dry before attaching the pouch.

B. Change the pouch once every 24 hr.: The frequency of pouch changes depends on individual client needs, stoma output, and the type of pouching system used. Changing the pouch every 24 hours may be unnecessary for some clients and could potentially cause skin irritation or damage.

C. Rub the peristomal skin dry after cleaning: Rubbing the peristomal skin dry after cleaning can cause irritation and damage to the skin. Instead, the nurse should gently pat the skin dry using a soft cloth or towel to avoid causing friction or trauma to the delicate skin surrounding the stoma.

D. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma:a allows for a better fit and helps prevent the edges of the stoma from coming into contact with stool, which can cause irritation and breakdown of the skin. A proper fit also helps ensure a secure seal and prevents leakage.