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Asking about medication cessation is important but not as immediate as addressing the client's current state of mind.

While discussing the partner may be relevant, it doesn't address the immediate safety concern.

Referring to the provider can be done later but ensuring immediate safety is the priority.

Sterile gloves, not clean gloves, should be worn when cleaning the inner cannula to prevent infection.

The skin around the stoma should be cleaned with a sterile saline solution, not full-strength hydrogen peroxide, which can irritate the skin and impair healing.

A precut tracheostomy dressing should be used under the tracheostomy flanges. Cutting a regular gauze pad can result in loose fibers that could enter the tracheostomy and pose a choking or infection risk.

Physician assistants typically assist with medical diagnoses and treatment plans, not rehabilitation.

Physical therapists focus on physical movement and rehabilitation, not typically assisting with activities of daily living such as feeding.

Social workers typically provide assistance with psychosocial support and community resources, which may be needed but are not as directly related to the client's physical limitations.

Informing the provider that the PCA is not providing adequate pain relief is not accurate in this scenario because the client rates their pain as 2, indicating that they are experiencing minimal discomfort.

Instructing the client to push the button more frequently is unnecessary as the client is already reporting low pain levels and has not expressed a need for additional medication.

Allowing the caregiver to push the PCA button when the client is resting is not recommended because PCA systems are designed for patient-controlled analgesia, ensuring that the patient manages their own pain without risking over-medication.

Enteral feeding, while important, can wait momentarily if the client's airway needs immediate attention.

Wound irrigation can be performed after ensuring the client's airway is clear and stable.

Urinary catheter care is important but can be prioritized after addressing acute respiratory needs.

Defamation involves harming a person's reputation, which is not occurring in this scenario.

Invasion of privacy involves intruding upon a person's private affairs, which is not relevant here.

Battery involves actual unwanted touching, which has not occurred yet in this scenario.

The nurse should not mix the medications together in a single syringe, because they might interact or precipitate.

The nurse should not combine the medications with the formula in the feeding bag, because this can alter the osmolality and nutrient content of the formula.

While diluting medications may be necessary for some drugs, it is not a general rule for all medications. Additionally, dilution with warm water may not be appropriate for all drugs, and the amount of water needed may vary. It's safer to use a standardized method, such as flushing the tube with sterile water.

Dentures should be left in place unless otherwise requested by the family or according to cultural practices.

Soft lighting is typically preferred in postmortem care to create a peaceful atmosphere.

Closing the client's eyes is typically part of postmortem care to create a peaceful appearance.

Regular weight-bearing exercise such as yoga can actually help reduce the risk of osteoporosis.

Vitamin A deficiency is not directly linked to osteoporosis.

Moderate alcohol consumption is not a significant risk factor for osteoporosis unless it leads to other lifestyle factors such as malnutrition or decreased physical activity.

The client should be repositioned at least every 2 hr, or more frequently if indicated by the client's condition or risk assessment.

The nurse should avoid elevating the head of the client's bed more than 30°, unless contraindicated, to reduce shearing forces on the sacrum and heels.

Massaging bony prominences can increase the risk of pressure injuries by causing friction and shearing forces on the skin.