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Inserting an NG tube is a complex and invasive procedure that requires the nurse's assessment and judgment. It is not appropriate to delegate this task to an assistive personnel.

Evaluating the healing of an incision is a skill that requires the nurse's knowledge and expertise. It is not appropriate to delegate this task to an assistive personnel.

Changing IV tubing is a sterile and technical procedure that involves the administration of fluids and medications. It is not appropriate to delegate this task to an assistive personnel.

Keeping the legs crossed while sitting can impair blood circulation and increase the risk of thrombus formation. This statement indicates a lack of understanding of the teaching.

Massaging the legs when they hurt can dislodge a thrombus and cause a pulmonary embolism or a stroke. This statement indicates a lack of understanding of the teaching.

Performing leg exercises once every 4 hours while awake is not enough to prevent thrombus formation. The client should perform leg exercises at least every hour or as prescribed by the nurse. This statement indicates a lack of understanding of the teaching.

SS for sliding scale is not a recommended abbreviation to use in medical documentation. The term “sliding scale” refers to a method of dosing insulin based on blood glucose readings, and using the abbreviation SS could lead to confusion with other terms or be misinterpreted.

OJ for orange juice should not be used as an abbreviation in medical records. While it may seem straightforward, using non-standard abbreviations like OJ can lead to misunderstandings, especially in a fast-paced healthcare environment where clarity is paramount.

SQ for subcutaneous is a commonly used abbreviation, but it is on the error-prone list due to potential misinterpretation. The ISMP suggests that SQ can be mistaken as “5 every,” and the “q” in “sub q” has been mistaken as “every” (e.g., a heparin dose ordered “sub q 2 hours before surgery” misunderstood as every 2 hours before surgery). Therefore, it is recommended to use “subcut” or “subcutaneously” instead.

Recommending small changes for the client to make to change her behavior over time is an action that the nurse should plan to take during the preparation stage of health behavior change, not the contemplation stage.

Assisting the client in setting goals to make the change is an action that the nurse should plan to take during the preparation stage of health behavior change, not the contemplation stage.

Developing a plan for the client to integrate the change into her lifestyle is an action that the nurse should plan to take during the action stage of health behavior change, not the contemplation stage.

A weight gain of 0.91 kg (2 lb) in 2 days is an expected finding for a client who is receiving continuous enteral feeding via NG tube, as it indicates that the client is meeting his or her nutritional needs.

A blood glucose level of 110 mg/dL is an expected finding for a client who is receiving continuous enteral feeding via NG tube, as it indicates that the client's blood glucose is within the normal range.

Diarrhea one time in a 24-hr period is an expected finding for a client who is receiving continuous enteral feeding via NG tube, as it can be a common side effect of enteral feeding due to the osmolality or composition of the formula.

Heating the formula to 40.5°C (105°F) is not an appropriate action for the nurse to take, as it can cause thermal injury to the client's gastrointestinal mucosa. The formula should be at room temperature or slightly warmed.

Aspirating residual volume every 4 hr is not an appropriate action for the nurse to take, as it can increase the risk of aspiration and infection. The nurse should aspirate residual volume before each feeding or every 6 to 8 hr.

Changing the tubing set every 72 hr is not an appropriate action for the nurse to take, as it can increase the risk of contamination and infection. The nurse should change the tubing set every 24 hr.

Cleansing the stoppers with povidone-iodine before withdrawing medication is not an appropriate action for the nurse to take, as it can cause an allergic reaction in the client who has a latex allergy. The nurse should use latex-free stoppers or avoid puncturing the stoppers.

Removing the stopcocks from IV tubing is not an appropriate action for the nurse to take, as it can compromise the sterility and integrity of the IV system. The nurse should use latex-free stopcocks or cover them with a latex-free barrier.

Ensuring that the gloves in the surgical suite are powdered gloves is not an appropriate action for the nurse to take, as it can increase the risk of latex sensitization and reaction. The nurse should use latex-free or powder-free gloves.

This is an incorrect action because it can cause tension on the catheter and increase the risk of trauma and infection.

This is an incorrect action because it can cause the drainage bag to become too heavy and pull on the catheter. The drainage bag should be emptied at least every 8 hours or when it is half full.

This is an incorrect action because it can cause kinking of the catheter and obstruct the flow of urine. The catheter should be taped to the upper thigh for female clients.

This is an incorrect entry because it does not specify the dose and route of the medication.

This is an incorrect entry because it uses subjective terms such as 'seems' and 'appear'. The nurse should use objective data to describe the wound.

This is an incorrect entry because it does not reflect the current assessment of the wound. The nurse should document any changes or progress of the wound healing.

This is an incorrect action because percussion should be performed over the chest wall, not the back. Percussion helps loosen the mucus in the lungs.

This is an incorrect action because postural drainage should be scheduled before meals or at least 2 hours after meals. Postural drainage after meals can cause nausea and vomiting.

This is an incorrect action because the client should exhale slowly and deeply during vibration. Vibration helps move the mucus up the airways.