The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?
Place the vial with the remainder of the medication into a locked drawer.
Withdraw the medication into a syringe and label it with the client’s name.
Ask another nurse to witness the medication being discarded.
Throw the vial into the trash in the presence of another nurse.
The Correct Answer is C
Choice A rationale
Placing the vial with the remainder of the medication into a locked drawer is not appropriate because it does not ensure proper documentation and accountability for the remaining medication. Controlled substances require strict documentation and disposal procedures.
Choice B rationale
Withdrawing the medication into a syringe and labeling it with the client’s name is not necessary and can lead to errors or contamination. The medication should not be stored for future use in this manner.
Choice C rationale
Asking another nurse to witness the medication being discarded is the correct action. This ensures proper documentation, accountability, and compliance with regulations for the disposal of unused or remaining medications, especially controlled substances.
Choice D rationale
Throwing the vial into the trash in the presence of another nurse is not appropriate. It does not ensure proper documentation, accountability, or safe disposal of the remaining medication. Controlled substances require specific disposal procedures to prevent misuse or diversion.
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Correct Answer is A
Explanation
Choice A rationale
Puts on new gloves when entering a client’s room. This action demonstrates an understanding of standard precautions, which are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. By putting on new gloves when entering a client’s room, the UAP is ensuring that they are not transferring any pathogens from one environment to another, thereby protecting both themselves and the client.
Choice B rationale
Uses sterile gloves when handling body fluids. While it is important to use gloves when handling body fluids, sterile gloves are not necessary unless performing a sterile procedure. Standard gloves are sufficient for most tasks involving body fluids, and the use of sterile gloves in these situations would be an unnecessary use of resources.
Choice C rationale
Keeps a pair of gloves in uniform pocket. This practice is not recommended as it can lead to contamination of the gloves. Gloves should be stored in a clean, dry place and should be taken from the box immediately before use. Keeping gloves in a pocket can expose them to contaminants, which can then be transferred to the client.
Choice D rationale
Dons sterile gloves when caring for clients with HIV. HIV is not transmitted through casual contact, and standard gloves are sufficient for routine care of clients with HIV. Sterile gloves are only necessary for sterile procedures, regardless of the client’s HIV status.
Correct Answer is C
Explanation
Choice A rationale
Telling the client to dress the right arm first is practical advice but does not address the client’s frustration and emotional state. It is important to acknowledge the client’s feelings to provide empathetic care.
Choice B rationale
Offering a class on dressing tomorrow does not address the immediate frustration and emotional response of the client. The client needs support and understanding in the moment.
Choice C rationale
Acknowledging that dressing must be a frustrating experience for the client shows empathy and understanding. It validates the client’s feelings and helps build a therapeutic relationship.
Choice D rationale
Mentioning a policy against staff harassment is inappropriate and does not address the client’s frustration. It may escalate the situation and damage the nurse-client relationship.