An older adult woman with end-stage heart disease is hospitalized for severe heart failure (HF). She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. Which action should the nurse take first?

Choice A reason: Veracity involves truthfulness, which is not the primary principle here. The nurse manager’s suggestions about support systems empower the staff member to seek help independently, emphasizing autonomy. Veracity would apply if the manager ensured honest communication, but the focus is on enabling self-directed action, not truth-telling.

Choice B reason: Autonomy is encouraged by suggesting support systems, empowering the staff member to make independent choices about managing personal issues. This principle respects the individual’s right to self-determination, aligning with ethical nursing practice. The manager’s guidance fosters decision-making, enabling the staff member to address emotional challenges proactively.

Choice C reason: Fidelity involves keeping promises or loyalty, which is not the focus. The nurse manager’s action centers on empowering the staff member to seek support, promoting autonomy. Fidelity would apply if the manager committed to ongoing support, but the emphasis is on enabling independent action, not obligation.

Choice D reason: Justice ensures fairness, which is irrelevant here. The nurse manager’s suggestions promote autonomy by encouraging the staff member to choose support systems. Justice would apply in equitable resource allocation, but this scenario focuses on individual empowerment, making autonomy the principle being encouraged by the manager’s actions.

Choice A reason: Using firm pressure to pass the tube through the glottis is dangerous, as the glottis leads to the trachea, risking respiratory complications. Gagging indicates possible misplacement or irritation. The correct path is through the esophagus, and forceful insertion could cause trauma or perforation, making this an unsafe and incorrect action.

Choice B reason: Giving sips of water during gagging is risky, as it could lead to aspiration, especially in a client with a postoperative ileus. Gagging suggests the tube may be misplaced or causing irritation. This action does not address the cause of gagging and could worsen the client’s condition, making it inappropriate.

Choice C reason: Removing the tube and attempting reinsertion is the safest response to gagging, which may indicate misplacement or client discomfort. This allows the client to recover and the nurse to reassess technique, ensuring correct esophageal placement. This action aligns with evidence-based practice for NGT insertion, prioritizing patient safety and comfort.

Choice D reason: Tilting the head backward may open the airway but does not facilitate esophageal tube passage and could misalign the tube toward the trachea. Gagging requires pausing and reassessing, not adjusting head position. This action risks incorrect placement and does not address the immediate issue, making it ineffective.