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Swallowing more than once after taking a bite of food: While this can be associated with difficulty swallowing, it is a subtle sign and not as clearly indicative of aspiration as choking or coughing.

Swallowing liquid immediately after taking a sip of a beverage: This reflects normal swallowing mechanics and does not indicate dysphagia.

Highly sensitive gag reflex: A strong gag reflex is actually a protective mechanism and not a sign of dysphagia. A diminished gag reflex would be more concerning.

Remove and reinsert the NG tube: This is invasive and not the first step. It should only be done if there's evidence of a problem that can't be fixed otherwise.

Request a prescription for a medication to ease the client's anxiety: This addresses the symptom but not the underlying cause (possible NG malfunction).

Irrigate the NG tube with 100 mL of sterile water: 100 mL is too much and could lead to aspiration. Also, this action comes after verifying equipment function.

Remove the PEG tube from the stoma and clean it with soap and water: The PEG tube is a surgically placed device and should never be removed by the nurse unless ordered or in an emergency (e.g., dislodgement).

Administer the bolus feeding through the PEG tube without flushing it first: Flushing before and after prevents clogging and ensures tube patency.

Skip the flushing step if the PEG tube is already patent: Even if the tube appears patent, flushing before and after feeds is still necessary to prevent build-up and blockage.

Provide assistance to bathroom: This is appropriate if the client feels the urge but not the priority when there’s a concern for urinary retention.

Offer the client fluids: Fluids help with hydration but not necessarily with retention if the bladder is already full.

Insert an indwelling urinary catheter: This is an invasive intervention and should only be done after confirming urinary retention with a scan.

Symphysis pubis: This is not used in NG tube measurement; it’s used in bladder catheterization or pelvic assessments.

Umbilicus: Not part of the measurement for NG tube insertion.

Brachial artery: Not relevant to NG tube placement.

Return gastric content into the gastrostomy tube: This is appropriate if residual volume is within acceptable range, but it’s not the first action.

Measure stomach contents: Measuring residual volume is necessary but is done after positioning the client properly.

Flush the tube with water: Flushing helps maintain patency but should be done after confirming placement and measuring residual.

Dairy products: Dairy is generally not known to irritate the bladder and is usually well tolerated.

Fresh vegetables: Fresh vegetables are high in fiber and beneficial; they are not bladder irritants.

Red meat: Red meat is not a common bladder irritant, although it may affect overall health.

Replace the external urinary catheter once each day: Replacement depends on the manufacturer's instructions and patient need, not a fixed daily schedule.

Connect the catheter to continuous wall suction: External urinary catheters are connected to a gravity drainage bag, not suction.

Insert the catheter into the client's urethra: This describes an internal (indwelling) catheter, not an external one.

"The end of the stoma will be painful after this procedure.": The stoma has no nerve endings, so it should not be painful, although the abdominal incision may be sore.

"You should expect your stoma to be a purple color.": A healthy stoma should be pink to red and moist; purple may indicate poor perfusion.

"Your colostomy will produce watery stool.” This would be true for an ileostomy. A sigmoid colostomy typically produces formed stool.