A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which order should the nurse perform the following steps?

(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Choice A Reason:

This is the correct action. A filter needle should be used when drawing medication from an ampule to prevent glass particles from being aspirated into the syringe and subsequently administered to the patient.

Choice B Reason:

Adding 0.5 ml of diluent to the medication is incorrect. Adding diluent to medication from an ampule is not a standard practice. Ampules usually contain pre-measured doses of medication and are designed for direct withdrawal without dilution. Adding diluent could alter the concentration and effectiveness of the medication.

Choice C Reason:

This is not necessary. Once the ampule is opened, it should be handled with care to avoid contamination, but cleansing the tip with an alcohol swab is not a standard practice since it does not effectively remove glass particles.

Choice D Reason:

This is incorrect. Ampules are not pressurized containers, and injecting air into an ampule is unnecessary and could cause the medication to spill out or create bubbles that interfere with accurate dosing.

Choice A Reason:

A client who has ulcerative colitis is correct. Ulcerative colitis, a type of inflammatory bowel disease (IBD), involves chronic inflammation and ulceration in the colon and rectum. This condition often results in bleeding from the inflamed mucosa, leading to the presence of blood in the stool that can be detected by a fecal occult blood test.

Choice B Reason:

A client who has stomatitis is incorrect. Stomatitis refers to inflammation in the mouth and does not typically cause bleeding in the gastrointestinal tract, which is what the fecal occult blood test detects. Stomatitis involves oral lesions or sores but does not directly impact stool blood content.

Choice C Reason:

A client who uses laxatives is incorrect. Laxative use does not necessarily cause bleeding in the gastrointestinal tract. While some laxatives can potentially irritate the intestinal lining, leading to minor bleeding in some cases, the presence of blood in the stool due to laxative use is less common compared to conditions like ulcerative colitis, where chronic inflammation and ulceration lead to significant bleeding.

Choice D Reason:

A client who has cholecystitis is incorrect. Cholecystitis is inflammation of the gallbladder and does not directly involve bleeding in the gastrointestinal tract. It typically presents with symptoms related to gallbladder inflammation such as abdominal pain, nausea, and vomiting, rather than causing bleeding that would be detected by a fecal occult blood test.