A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I don't want any more treatment: just make me comfortable." The nurse should document that the client is in which of the following stages of grief?

Rationale

A. Access the online drug formulary for an unfamiliar medication: Consulting a reliable drug reference ensures the nurse understands the medication’s indications, dosage, contraindications, side effects, and interactions. This step is essential when administering a medication for the first time to promote safe and informed practice.

B. Use one patient identifier prior to medication administration: Safe medication administration requires two patient identifiers (e.g., name and date of birth) to verify the correct client. Using only one identifier increases the risk of medication errors and does not meet standard safety protocols.

C. Read the medication label twice prior to administration: Best practice is to read the medication label three times, when removing it from storage, before preparing it, and before administering it to ensure accuracy. Reading only twice may allow for errors in drug selection or dosage.

D. Ask the client if they have ever taken a similar medication: While obtaining medication history from the client is useful, it does not replace verification of proper dosage, route, or interactions. Client recollection may be incomplete or inaccurate, so relying on a reference is safer for first-time administration.

Rationale

A. Set the suction device to 120 mm Hg: Adult nasopharyngeal suctioning requires suction pressure between 100 and 150 mm Hg to effectively remove secretions without damaging mucosal tissue. Setting the device to 120 mm Hg falls safely within this range and provides adequate negative pressure for efficient suctioning.

B. Apply suction to the catheter during insertion: Suction should never be applied during catheter insertion because it increases the risk of mucosal injury and can cause hypoxia. The catheter must be inserted gently to the appropriate depth before suctioning is activated on withdrawal. This helps protect the airway structures and maintains patient safety during the procedure.

C. Have the client tuck his chin to his chest during suctioning: The chin-to-chest position narrows the airway passage and makes catheter insertion more difficult. Nasopharyngeal suctioning requires the "sniffing" position, where the head is slightly extended to align the airway for smoother catheter passage.

D. Apply a petroleum-based lubricant to the catheter: Petroleum-based lubricants should not be used because they can irritate mucous membranes and pose a risk if aspirated. Water-soluble lubricants are recommended since they reduce friction, minimize trauma, and dissolve easily if small amounts enter the airway.