A nurse is caring for a client who is receiving a continuous enteral tube feeding and develops diarrhea. Which of the following actions should the nurse take?

The correct answer is choice C. Clean the stoma using an inward to outward circular motion.

Choice A rationale:

Cleansing the inner cannula with isopropyl alcohol is not recommended because it can be irritating to the mucosa. Instead, the inner cannula should be cleaned with sterile saline or a prescribed solution.

Choice B rationale:

Preparing sterile supplies after removing the inner cannula is not the correct sequence. Sterile supplies should be prepared before starting the procedure to maintain sterility and efficiency.

Choice C rationale:

Cleaning the stoma using an inward to outward circular motion is correct because it helps to prevent the spread of microorganisms from the outer skin to the stoma site, reducing the risk of infection.

Choice D rationale:

Ensuring at least three finger widths of space under tracheostomy ties is incorrect. The correct practice is to ensure that only one to two finger widths can fit under the tracheostomy ties to ensure they are secure but not too tight.

The correct answer is D.

Verify the medication three times with the medication administration record. The nurse should follow the six rights of medication administration: right client, right drug, right dose, right route, right time, and right documentation. To ensure the right drug and dose, the nurse should check the medication label against the medication administration record (MAR) three times: before removing the medication from the storage area, before preparing or measuring the medication, and before administering the medication to the client.

The nurse should also use two identifiers (such as name and date of birth) to verify the right client. The nurse should document medication administration after giving the medication, not before, to avoid errors and ensure accuracy. The nurse should administer time-critical medications within 30 minutes before or after the scheduled time, not 60 minutes.