A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?

Choice A reason: Instructing another nurse to record risks errors; the receiving nurse must document directly for accuracy. Scientifically, this violates chain-of-command and transcription protocols, as firsthand recording ensures fidelity to the provider’s intent, reducing miscommunication in medication orders.

Choice B reason: Asking for spelling clarifies the medication, preventing errors like sound-alikes (e.g., Celexa vs. Celebrex). Scientifically, this aligns with safety standards, as precise identification ensures correct drug administration, critical in telephone orders where auditory mistakes are common.

Choice C reason: Withholding until signed delays care; telephone orders allow immediate action with later signature (e.g., 24-48 hours). Scientifically, this contradicts urgent care needs, as timely treatment outweighs procedural lag, provided documentation and verification are complete.

Choice D reason: Recording date and time establishes a legal timeline, ensuring accountability and sequence of care. Scientifically, this is mandatory in telephone orders, supporting traceability and adherence to protocols, critical for auditing and patient safety in medication administration.

Choice E reason: Read-back confirmation verifies accuracy, reducing errors in verbal orders. Scientifically, this is evidence-based, as it ensures the provider’s intent matches the nurse’s record, safeguarding against misheard doses or drugs, a key step in safe prescribing practices.

Choice A reason: Applying suction while inserting risks trauma to nasal mucosa, as continuous pressure can tear delicate tissues or cause bleeding. Proper technique involves inserting without suction, then applying it on withdrawal to safely remove secretions, minimizing injury and ensuring effective clearance without damaging the airway lining.

Choice B reason: Intermittent suction for 30 seconds exceeds safe limits; guidelines recommend 10-15 seconds to avoid hypoxia. Prolonged suction depletes oxygen in the airway, especially in nasopharyngeal suctioning, where ventilation is obstructed, risking respiratory distress or cardiac complications in an adult client with compromised breathing.

Choice C reason: Inserting the catheter 10 cm (4 in) is too shallow for nasopharyngeal suctioning in adults, where 16-20 cm reaches the pharynx. Insufficient depth fails to clear secretions effectively, leaving mucus in lower airways, potentially worsening obstruction or infection, as the catheter must target the secretion source accurately.

Choice D reason: Waiting 1 minute between attempts allows oxygen levels to stabilize, preventing hypoxia during nasopharyngeal suctioning. This interval ensures the client reoxygenates after airway occlusion, reducing risks of desaturation or arrhythmia, aligning with safe practice to maintain respiratory stability while clearing mucus effectively in adults.