A nurse is assisting in the care of a client

Which of the following interventions should the nurse plan to implement? Select all that apply.

A) Can you tell me about the stresses in your life?: While identifying stressors is important in understanding the context of the client’s feelings, the priority in the context of suicidal ideation is to assess the immediacy of danger to the client. Understanding the plan and means for suicide is the first step in evaluating the severity of the situation.

B) "Do you have a plan for harming yourself?": This is the priority question because it directly assesses the immediacy and seriousness of the client’s suicidal ideations. Knowing whether the client has a specific plan allows the nurse to determine the level of risk and take appropriate action, such as ensuring the client is safe and arranging for immediate intervention, including hospitalization if necessary.

C) Do you have someone to discuss your feelings with?: While social support is important, this question does not immediately address the severity of the suicidal ideation. If the client is at high risk, the nurse must first assess the immediate danger posed by the suicidal thoughts and actions before discussing coping strategies or support systems.

D) Has anyone in your family ever died by suicide?: Although a family history of suicide can increase risk, this question is secondary to directly assessing the client's current risk. The focus should first be on evaluating the client’s immediate safety, such as whether they have a plan and the means to harm themselves.

A) Mix the 2 medications together prior to administration: It is not recommended to mix medications together before administering them through an NG tube unless specifically instructed by a healthcare provider or the pharmacy. Some medications can interact or precipitate when combined, which could reduce their effectiveness or cause harmful reactions. Therefore, it is safer to administer each medication separately, followed by a flush.

B) Add the medications to a small amount of the formula: Medications should not be mixed with enteral feeding formula, as it can affect the absorption of the medication and alter its effectiveness. Additionally, the medications could interact with components of the formula, leading to complications or reduced efficacy.

C) Flush the tube with at least 30 mL of sterile water prior to administering the medications: This is the correct action. Flushing the NG tube with 30 mL of sterile water before administering medications helps ensure the tube is clear and patent, preventing clogging. It also prepares the tube to receive the medications, ensuring proper delivery into the gastrointestinal tract.

D) Connect the NG tube to suction 10 minutes after administration of the medications: Connecting the NG tube to suction immediately after medication administration could remove the medications before they are absorbed. It is important to wait at least 30 minutes after administering medications before connecting the NG tube to suction to ensure the medication is absorbed adequately.