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
Using the syringe to remove the specimen from the catheter requires the nurse to wear gloves to maintain sterility and prevent contamination. Gloves protect both the nurse and the patient from potential pathogens present in the urine.
Choice B rationale
Transporting the urine specimen to the laboratory does not require gloves as the specimen is already secured in a biohazard bag, minimizing the risk of contamination.
Choice C rationale
Recording the output on the flowsheet in the client’s room does not involve direct contact with the urine specimen, so gloves are not necessary.
Choice D rationale
Clamping the urinary catheter prior to the collection does not require gloves as it is a preliminary step that does not involve direct contact with the urine.
Correct Answer is B
Explanation
Choice A rationale
Reporting any change in urine color is not a priority intervention for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink. The focus should be on comfort measures.
Choice B rationale
Keeping mucous membranes moist is essential for comfort in terminally ill clients who are mouth breathing and refusing fluids. This can be achieved by offering ice chips, sips of water, or using a moist cloth.
Choice C rationale
Recording the client’s daily weight is not a priority in this situation as the client is terminally ill and the focus should be on comfort rather than monitoring weight.
Choice D rationale
Maintaining the client in high Fowler’s position is not necessary unless it helps with breathing. The priority is to keep the client comfortable.