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 C
Explanation
Choice A rationale
A urine specific gravity of 1.015 is within the normal range and does not indicate dehydration. Dehydration typically results in a higher urine specific gravity due to the concentration of solutes in the urine.
Choice B rationale
A urine specific gravity of 1.005 is lower than normal and indicates dilute urine, which is not consistent with dehydration. Dehydration would result in more concentrated urine with a higher specific gravity.
Choice C rationale
A urine specific gravity of 1.035 indicates highly concentrated urine, which is consistent with dehydration. When a client has a history of vomiting and diarrhea, they are likely to be dehydrated, leading to a higher urine specific gravity.
Choice D rationale
A urine specific gravity of 1.025 is slightly higher than normal but not as high as 1.035. While it may indicate some level of concentration, it is not as indicative of severe dehydration as a specific gravity of 1.035.
Correct Answer is B
Explanation
Choice A rationale
Contraction of the left pupil when light shines in the right eye is a normal consensual pupillary response and does not need to be documented in charting by exception. This finding is within normal limits and does not indicate any deviation from the expected outcome.
Choice B rationale
Basilar lung sounds that are diminished in the left lung should be documented because this finding deviates from the normal lung sounds and indicates a potential issue that needs further investigation. Charting by exception focuses on documenting abnormalities or deviations from the norm.
Choice C rationale
Active bowel sounds in the lower right quadrant are a normal finding and do not need to be documented in charting by exception. This assessment is within normal limits and does not indicate any deviation from the expected outcome.
Choice D rationale
Capillary refill of 2 seconds in the lower right foot is a normal finding and does not need to be documented in charting by exception. This assessment is within normal limits and does not indicate any deviation from the expected outcome.