A nurse is caring for a client who has a clogged NG tube. Which of the following actions should the nurse take?

Rationale

A. Ensure the client wears a surgical mask when they are outside of their room: The client has no current respiratory symptoms and no evidence of an active infection requiring droplet or airborne precautions. The previous pneumonia noted in the history is resolved. Standard precautions are therefore adequate at this time.

B. Place the client on contact precautions: The sudden onset of abdominal cramping and multiple loose stools after antibiotic therapy raises concern for possible C. difficile infection. Initiating contact precautions promptly helps prevent the spread of spores, which can contaminate surfaces and infect other clients. Early isolation is critical when diarrhea develops in a client receiving broad-spectrum antibiotics.

C. Clarify the prescription for amoxicillin with the provider: The client’s documented penicillin allergy places them at risk for hypersensitivity reactions when given amoxicillin, a penicillin-class antibiotic. Even if doses have been tolerated so far, the risk of an allergic event remains significant.

D. Hold the dose of levothyroxine: Levothyroxine should be administered consistently to maintain stable thyroid hormone levels, and the client shows no findings indicating the need to withhold it. Vital signs and clinical status do not suggest complications related to thyroid therapy or excess dosing. Disrupting routine thyroid management could worsen metabolic balance.

E. Recommend increasing the dose of metoprolol: Vital signs demonstrate stable blood pressure and heart rate, showing no evidence of inadequate control of hypertension. Increasing the dose without indication could result in hypotension or bradycardia, which may compromise perfusion. No assessment data support changing this medication at this time.

F. Request a prescription for an antiemetic medication: The client continues to experience persistent nausea and has demonstrated reduced dietary intake for several days, which may impair hydration and oral medication tolerance. Addressing nausea helps support nutritional intake and overall recovery.

Rationale:

A. Circular Red Area: This is a Stage 1 Pressure Injury (non-blanchable erythema or shallow ulcer).

B. Bruise on Leg: This shows contusion/bruising (ecchymosis) and possible swelling, which is a closed injury, not an open wound that requires healing by intention.

C. Sutured Incision (Primary intention): The wound edges are cleanly approximated (brought together) with sutures, staples, or adhesive. Minimal tissue loss occurred. Healing occurs rapidly, with minimal granulation tissue and minimal scarring. The image showing the clean, surgical incision closed with staples or sutures.

D. Open Ulcer/Pressure Injury (Secondary Intention): The wound has significant tissue loss, irregular borders, and the edges cannot be approximated (closed). The wound is left open to heal by granulation (formation of new connective tissue) from the bottom up. This process is slower and results in a larger, more noticeable scar.