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.)

A. Extend the client's neck while securing the ties: This action can compromise the client's airway and is not recommended during tracheostomy tie changes. The client's neck should be in a comfortable, neutral position during the procedure.

B. Use a quick-release knot to secure the ties: Quick-release knots are not typically used for securing tracheostomy ties. Instead, a secure knot that can be easily tied and untied is preferred to ensure the stability of the tracheostomy tube.

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

Allowing space for three fingers is not a standard practice for tracheostomy ties. The ties should be snug but not overly tight, typically allowing for one or two fingers’ width to ensure proper fit and comfort.

D. When changing tracheostomy ties, it is essential to maintain airway security and prevent accidental dislodgement of the tracheostomy tube. The nurse should secure the new ties first before removing the old ones to ensure the tracheostomy remains stable.

A. "Enjoy the time you have and do the things you want to do":

While this response may seem supportive, it does not address the client's expressed desire for aggressive treatment. It is important for the nurse to acknowledge the client's wishes and provide appropriate support and information to help them make decisions about their care.

B. "Hospice care is the best thing for you at this time":

While hospice care may be appropriate for some clients with terminal illnesses, it is not appropriate to assume that it is the best option for every client. The nurse should not impose their own beliefs or preferences onto the client and should instead support the client in exploring their options and making decisions based on their individual needs and preferences.

C. "You need to understand that you have very little time left":

This response may be seen as dismissive or insensitive to the client's wishes for aggressive treatment. It does not acknowledge the client's autonomy or right to make decisions about their own care. The nurse should approach the situation with empathy and respect for the client's wishes, while also providing support and information to help them make informed decisions.

D. "I will contact your provider to discuss your options."

The client has expressed a desire for aggressive treatment, and it is important for the nurse to respect the client's autonomy and preferences. By stating that they will contact the provider to discuss the client's options, the nurse ensures that the client's wishes are communicated effectively and that they receive appropriate information and support to make informed decisions about their care.