A nurse is caring for an elderly client diagnosed with a urinary tract infection (UTI). The family reports an abrupt onset of altered mental status, disorientation, and intermittent hallucinations. The nurse would identify these signs to be consistent with which sensory alteration?

Choice A Reason:

Lubricate the suction catheter tip with sterile saline is important to ensure smooth insertion and reduce trauma to the tracheal mucosa. However, this is not the first step. Preoxygenation is crucial to prevent hypoxia during the suctioning process.

Choice B Reason:

Perform chest physiotherapy prior to suctioning can help mobilize secretions, making them easier to remove. While beneficial, it is not the immediate first step. Ensuring the client is adequately oxygenated takes precedence.

Choice C Reason:

Hyperventilate the client on 100% oxygen prior to suctioning is correct. This step is essential to prevent hypoxia during suctioning. Suctioning can temporarily reduce oxygen levels, so preoxygenating the client helps maintain adequate oxygenation throughout the procedure.

Choice D Reason:

Suction two to three times with a 60-second pause between passes is a recommended practice to allow the client to recover between suctioning attempts. However, this step follows the initial preoxygenation.

Choice A Reason:

Washing the area of the puncture thoroughly with soap and water is the first and most immediate action the nurse should take. This step helps to reduce the risk of infection by removing any potential contaminants from the puncture site. It is a crucial initial response to any needlestick injury to minimize the risk of bloodborne pathogen transmission. Proper hand hygiene is essential in preventing infections and ensuring the safety of healthcare workers.

Choice B Reason:

Notifying employee health services is an important step that should follow the initial first aid. Employee health services will provide further evaluation, testing, and follow-up care as needed. They will also guide the nurse on any necessary post-exposure prophylaxis and additional steps to take. However, this is not the first action to take immediately after the injury.

Choice C Reason:

Completing an incident report is a necessary step to document the needlestick injury. This report helps in tracking and preventing future incidents, ensuring that proper protocols are followed, and providing data for workplace safety improvements. While important, this step should be taken after the initial first aid and notification of employee health services.

Choice D Reason:

Reporting the incident to the charge nurse is also an important step in the process. The charge nurse needs to be informed about the incident to ensure that appropriate follow-up actions are taken and to provide support to the affected nurse. However, this step should come after the immediate first aid and notification of employee health services.