A nurse is assisting in the care of a client who has pneumonia.

Exhibits

The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include? Select all that apply.

A. Mark the length to be inserted on the tube with tape: Marking the insertion length is important to ensure correct placement, but this step should occur after assessing which nare to use and preparing the client.

B. Instruct the client to hyperextend her neck: Hyperextending the neck is not recommended during NG tube insertion; instead, the client should slightly flex the neck to facilitate tube passage.

C. Place a water-based lubricant on the tip of the tube: Lubricating the tube reduces discomfort and eases insertion, but this step comes after selecting the nostril and preparing the client.

D. Compare the patency of the client’s nares: Assessing which nostril is more patent is the first priority to ensure the tube is inserted through the nare that offers the least resistance, reducing trauma and improving comfort during insertion.

A. Speak with a loud voice while providing the information: Increasing the volume of speech is not effective for clients with expressive aphasia because their difficulty lies in producing language, not hearing. Speaking loudly may cause frustration or discomfort without improving communication.

B. Determine the client's ability to use a communication board: Assessing the client’s ability to use a communication board is an essential strategy to facilitate effective communication. Augmentative tools like communication boards can help them convey their needs and participate in teaching.

C. Provide the teaching without expecting the client to respond: Teaching without expecting any response can lead to missed opportunities for interaction and engagement. Encouraging some form of response, even nonverbal or through assistive devices, helps evaluate the client’s comprehension and maintains their involvement.

D. Avoid the use of facial gestures during the instructions: Facial gestures, body language, and visual cues play an important role in enhancing communication for clients with aphasia. Using expressive gestures should be encouraged to supplement verbal teaching and promote better comprehension.