A charge nurse is observing a newly-licensed nurse insert an Indwelling urinary catheter for a male client. Which of the following actions by the newly-licensed nurse requires intervention by the charge nurse?

A. Checking the stockings for wrinkles is an important action. Wrinkles or folds in the stockings can create areas of increased pressure, which might lead to discomfort or skin breakdown and reduce the effectiveness of the stockings in preventing DVT. Ensuring that the stockings are smooth and free from wrinkles helps maintain proper compression and comfort.
B. Measuring the size of the client's foot is not typically required for properly fitting antiembolic stockings. The key measurements for antiembolic stockings are usually related to the calf, thigh, and sometimes the knee, not the foot.
C. Removing the stockings once each day is not usually recommended unless specifically instructed by a healthcare provider. Antiembolic stockings are generally worn continuously throughout the day and removed only for specific reasons, such as skin assessment or hygiene.
D. Applying the stockings while the client is sitting in a chair is not the preferred method. Antiembolic stockings should be applied while the client is lying down or in a supine position. This helps ensure that the stockings are applied evenly and that they provide consistent compression without causing undue pressure or discomfort.

A. The supine position increases the risk of aspiration, where food or liquid could enter the airway and potentially cause aspiration pneumonia. To minimize this risk, the client should be positioned in a semi- Fowler’s position (head of the bed elevated at 30-45 degrees) during feedings.
B. Aspirating gastric residual volumes is a standard practice to check for proper digestion and tolerance of the feeding. Generally, a residual of up to 250-500 mL can be acceptable depending on institutional policy and client condition. This action does not necessarily require intervention unless specific guidelines indicate otherwise.
C. Irrigating the NG tube with tap water is a common practice to ensure the tube remains patent and to help clear any residual feeding material from the tube. Tap water is generally considered acceptable for this purpose, though some facilities may use sterile or distilled water to avoid any potential infections.
D. Administering the feeding through a syringe barrel by gravity is a standard method for intermittent tube feedings. This technique allows the feeding to flow slowly into the stomach without excessive pressure, which can help prevent complications such as nausea or cramping.