A nurse is about to administer a daily dose of potassium chloride 20 mEq suspension orally.

The available amount is potassium chloride suspension 10 mEq/mL.

How many mL should the nurse administer?

Choice A rationale

While it is within the nurse’s scope of practice to communicate with the doctor regarding the patient’s condition, applying restraints should not be the first course of action when a patient frequently tries to remove their IV catheter. Restraints should only be used as a last resort when all other interventions have failed and the patient’s safety is at risk.

Choice B rationale

This is the correct response. Covering the catheter so the patient can’t see it may help to reduce the patient’s urge to remove it. This is a non-invasive intervention that respects the patient’s autonomy while also ensuring their safety.

Choice C rationale

Waiting until nighttime to see if the patient continues the behavior may not be the best course of action. If the patient is frequently trying to remove their IV catheter, it is important to address the issue promptly to prevent potential harm.

Choice D rationale

Applying restraints immediately is not the best course of action. Restraints should only be used as a last resort when all other interventions have failed and the patient’s safety is at risk.

Choice A rationale

Lubricating the suction catheter tip with sterile saline is not recommended because it can introduce bacteria into the tracheostomy tube and cause infection.

Choice B rationale

Hyperventilating the patient on 100% oxygen prior to suctioning is not necessary and can cause complications such as oxygen toxicity.

Choice C rationale

Performing chest physiotherapy prior to suctioning is not typically done during tracheostomy care. Chest physiotherapy is a separate procedure that involves physical techniques to remove mucus from the respiratory tract.

Choice D rationale

Suctioning two to three times with a 60-second pause between passes is the correct action. This helps to remove secretions effectively without causing hypoxia.