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:

A filter needle is used to prevent any glass particles from entering the syringe when drawing medication from an ampule, as ampules are made of glass that can sometimes break and leave shards.

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:

The ampule should be cleansed before opening to remove any potential contaminants. Once the ampule is opened, the inside of the ampule and the medication should be considered sterile, so there is no need to cleanse the tip after opening.

Choice D Reason:

Injecting air into the ampule prior to drawing the medication into a syringe is incorrect. This action is not typically necessary when withdrawing medication from an ampule. Some medications may require air to equalize pressure, but it's crucial to follow specific guidelines for each medication. In most cases, creating positive pressure by injecting air into the ampule is not recommended, as it could affect the stability or integrity of the medication.

Choice A Reason:

Obtaining urine from the drainage bag if a urinary specimen is required is incorrect.

While obtaining urine from the drainage bag might seem practical for specimen collection, it's not the recommended method due to potential contamination of the specimen. A sterile sampling port or aspirating urine from the catheter tubing is a more appropriate technique.

Choice B Reason:

Using a catheter securing device to hold the catheter in place is correct. Securing the catheter with a proper securing device helps prevent unnecessary movement or tension on the catheter, reducing the risk of trauma to the urinary tract and ensuring stability for the catheter.

Choice C Reason:

Positioning the drainage bag higher than the client's bladder is incorrect. Positioning the drainage bag higher than the bladder can lead to backflow or reflux of urine, increasing the risk of urinary tract infections. The drainage bag should be placed below the level of the bladder to facilitate proper drainage.

Choice D Reason:

Changing the catheter bag every 3 days and as needed is incorrect. Routine changing of catheter bags every three days without clinical indication for changing can increase the risk of introducing infection. Catheter bags are changed based on clinical indications or when they are soiled or damaged, not on a fixed time schedule.