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Irrigate the NG tube with a carbonated beverage: Carbonated beverages are not recommended because they can damage the tubing material and are ineffective at dissolving clogs. They may also introduce unwanted substances into the gastrointestinal tract. Current best practice favors warm sterile water rather than soda or acidic liquids.

Use a 1 mL syringe to flush the NG tube: A 1 mL syringe generates dangerously high pressure that could rupture the tube or injure gastric tissue. Large-volume syringes, typically 30–60 mL, are used to maintain safe, low pressure during flushing. Using a very small syringe creates risk without increasing the likelihood of clearing the obstruction.

Place the patient in prone position: Position changes do not clear mechanical obstructions in the NG tube and may compromise comfort or breathing. Safe NG tube management prioritizes flushing techniques rather than altering the client’s position. Changing posture will not resolve the cause of the clog and may delay appropriate intervention.

Apply a transfer belt to the client prior to transferring to the stretcher: Transfer belts are used for clients who can stand or provide some degree of weight-bearing support. An immobile 104.3-kg client cannot safely assist with the transfer, making the belt ineffective and unsafe. Using a transfer belt in this scenario increases the risk of falls and caregiver injury.

Have the client roll onto a transfer board and pull the board onto the stretcher: This technique requires the client to participate by rolling, which is not feasible for someone who is immobile. Pulling a transfer board with the client on it creates unnecessary shear forces that increase the risk of skin breakdown. This approach is neither safe nor appropriate for a heavy, immobile patient.

Move the client's upper body onto the stretcher first: Moving the client unevenly in sections can cause spinal misalignment and increases the risk of caregiver injury due to poor body mechanics. This technique also creates friction on the client’s skin and may cause discomfort or tissue injury. A coordinated lateral transfer keeps the body aligned and is recommended.

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

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.

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.

Apply suction to the catheter during insertion: Suction should never be applied during catheter insertion because it increases the risk of mucosal injury and can cause hypoxia. The catheter must be inserted gently to the appropriate depth before suctioning is activated on withdrawal. This helps protect the airway structures and maintains patient safety during the procedure.

Have the client tuck his chin to his chest during suctioning: The chin-to-chest position narrows the airway passage and makes catheter insertion more difficult. Nasopharyngeal suctioning requires the "sniffing" position, where the head is slightly extended to align the airway for smoother catheter passage.

Apply a petroleum-based lubricant to the catheter: Petroleum-based lubricants should not be used because they can irritate mucous membranes and pose a risk if aspirated. Water-soluble lubricants are recommended since they reduce friction, minimize trauma, and dissolve easily if small amounts enter the airway.

"Your provider wants you to take this medication.": This response focuses on the provider’s wishes rather than the client’s concerns and may make the client feel dismissed. It does not support shared decision-making or encourage the client to express what is worrying them about treatment. Such a statement can create resistance instead of promoting understanding.

"Why don't you want to undergo monitoring?": Asking “why” can feel accusatory or confrontational, which may make the client defensive. Although understanding the reason is important, this phrasing is not therapeutic and can shut down communication. A more open and neutral statement would be needed to explore the client's concerns effectively.

"Regular monitoring is not difficult and will ensure that you remain healthy.": This response minimizes the client’s feelings and assumes they will find the monitoring easy. It offers reassurance without addressing the client’s specific concerns or allowing them to express their viewpoint. It does not promote meaningful dialogue about their hesitation.

Poor skin turgor: Poor skin turgor is typically a sign of fluid volume deficit, not excess. In fluid overload, the skin may appear edematous or stretched rather than dehydrated. Assessing turgor helps differentiate between dehydration and overhydration.

Thready pulse: A thready, weak pulse is often associated with hypovolemia due to reduced circulating volume. In fluid volume excess, pulses are usually full and bounding because of increased intravascular pressure. Pulse quality provides insight into circulatory status.

Flat neck veins: Flat neck veins are associated with low central venous pressure, typically seen in dehydration or hypovolemia. In fluid overload, neck veins are often distended due to increased venous pressure. Jugular vein assessment is a key indicator of intravascular volume status.

The provider obtains verbal consent for the procedure without witnessing the client's signature: While verbal consent may be appropriate for some low-risk procedures, most invasive or high-risk procedures require written consent. Obtaining consent without documentation does not meet legal or ethical standards for informed consent and may place both the client and provider at risk.

The nurse's role is to provide the client with initial information about the procedure prior to obtaining informed consent: The nurse’s role is to reinforce teaching, clarify information, and ensure the client comprehends the procedure. Nurses can answer questions and verify understanding but do not obtain legal consent for invasive procedures.

Clients are unable to change their mind once a consent form is signed: Clients have the right to withdraw consent at any time, even after signing the consent form. Respecting autonomy means that the client can refuse or discontinue a procedure without penalty, and this right must be communicated as part of the informed consent process.

Respiratory therapist: Respiratory therapists focus on airway management, pulmonary function, and respiratory interventions. Assistance with dressing is not within their scope of practice and does not relate to pulmonary or ventilatory needs. Reporting dressing difficulties to them would not contribute to the client’s functional recovery.

Physical therapist: Physical therapists focus on mobility, strength, range of motion, and gait training. While they may help with lower extremity function, they do not specialize in teaching or assisting with self-care activities like dressing, which is a focus of occupational therapy.

Social worker: Social workers address psychosocial needs, discharge planning, and community resources. They are not directly involved in the client’s ability to perform activities of daily living such as dressing, so reporting this information to them would not address the immediate functional concern.