A nurse is transcribing a client’s prescription for erythromycin 500 mg four times per day. Which of the following information should the nurse clarify with the provider?

Choice A reason: Decreased blood pressure is not a direct sign of fluid overload; it may indicate hypovolemia or shock. Fluid overload increases intravascular volume, typically raising pressure initially. This finding contradicts the excess fluid state in enteral feeding complications, where the body retains too much water, affecting other systems first.

Choice B reason: Decreased skin turgor suggests dehydration, not fluid overload. In overload, excess fluid accumulates in tissues, potentially causing edema, not poor elasticity. Enteral feeding can lead to overhydration if mismanaged, making turgor an unreliable indicator here, as it reflects fluid deficit rather than the excess seen in this scenario.

Choice C reason: Weight loss occurs with fluid loss or malnutrition, not overload. Fluid overload from enteral feedings causes rapid weight gain due to water retention. This finding opposes the expected physiology of excess fluid, where the body holds onto water, increasing mass, not shedding it as in dehydration.

Choice D reason: Crackles in the lungs indicate fluid overload, as excess fluid from enteral feedings backs up into pulmonary circulation, causing pulmonary edema. This audible sign reflects fluid escaping into alveoli, impairing gas exchange, a common complication when intake exceeds the body’s ability to excrete water effectively.

Choice A reason: Applying suction while inserting risks trauma to nasal mucosa, as continuous pressure can tear delicate tissues or cause bleeding. Proper technique involves inserting without suction, then applying it on withdrawal to safely remove secretions, minimizing injury and ensuring effective clearance without damaging the airway lining.

Choice B reason: Intermittent suction for 30 seconds exceeds safe limits; guidelines recommend 10-15 seconds to avoid hypoxia. Prolonged suction depletes oxygen in the airway, especially in nasopharyngeal suctioning, where ventilation is obstructed, risking respiratory distress or cardiac complications in an adult client with compromised breathing.

Choice C reason: Inserting the catheter 10 cm (4 in) is too shallow for nasopharyngeal suctioning in adults, where 16-20 cm reaches the pharynx. Insufficient depth fails to clear secretions effectively, leaving mucus in lower airways, potentially worsening obstruction or infection, as the catheter must target the secretion source accurately.

Choice D reason: Waiting 1 minute between attempts allows oxygen levels to stabilize, preventing hypoxia during nasopharyngeal suctioning. This interval ensures the client reoxygenates after airway occlusion, reducing risks of desaturation or arrhythmia, aligning with safe practice to maintain respiratory stability while clearing mucus effectively in adults.