A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)

Correct answer: B

A. Use a quick-release knot to secure the ties:

This is not the best practice. Quick-release knots are not recommended for securing tracheostomy ties because they can loosen more easily, increasing the risk of accidental decannulation (dislodging the tracheostomy tube). The ties should be securely fastened with a non-quick-release knot.

B. Cut the old ties after the new ties are secured:

This is the safest approach. It ensures the tracheostomy tube remains secure throughout the change.

C. Allow space for three fingers under the ties when securing:

Two fingers is the recommended space to allow for breathing comfort and prevent the tube from being too loose..

D. Extend the client's neck while securing the ties:

This is not the correct action. Hyperextending the client's neck during tracheostomy tie changes can cause discomfort and may compromise the integrity of the tracheostomy tube placement. The neck should be in a neutral position to maintain proper alignment.

A. Administer an antiemetic:

Administering an antiemetic might be necessary to relieve nausea and vomiting, but it is not the first action. Before administering medications, it is essential to assess the client's condition and gather information about the underlying cause of the symptoms.

B. Offer pain medication:

Offering pain medication is not the first action. The nurse needs to assess the client's condition, determine the cause of the pain, and gather more information before administering pain relief. Administering pain medication before a thorough assessment can mask important clinical signs and symptoms.

C. Palpate the abdomen:

Palpating the abdomen is an important step in the assessment, but it should follow auscultation of bowel sounds. Palpation can be deferred if there is concern about possible inflammation (as in suspected appendicitis) to avoid causing further irritation.

D. Auscultate bowel sounds:

This is the correct action. Auscultating bowel sounds is the first step in assessing the gastrointestinal (GI) function. The reported symptoms of right lower quadrant pain, nausea, and vomiting could be indicative of various GI issues, such as appendicitis. Assessing bowel sounds helps the nurse gather information about the status of peristalsis and potential obstructions.