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 D
Explanation
Choice A rationale
Providing a back rub at bedtime can help promote relaxation and improve sleep quality. However, it does not directly address the issue of wandering, which poses a safety risk for the client. The primary concern should be ensuring the client’s safety by preventing wandering.
Choice B rationale
Applying wrist restraints to prevent wandering is not an appropriate first intervention. Restraints should be used as a last resort when other measures have failed, and they can cause physical and psychological harm to the client. The focus should be on non-restrictive interventions to ensure safety.
Choice C rationale
Administering a PRN sedative prescription may help the client sleep, but it should not be the first intervention. Sedatives can have side effects and may not address the underlying cause of the client’s wandering. Non-pharmacological interventions should be tried first.
Choice D rationale
Leaving the door to the client’s room open slightly allows the client to see and hear staff members as they pass by, which can help reduce feelings of isolation and anxiety. This intervention addresses both the client’s sleep issues and wandering behavior by providing a sense of security and supervision.
Correct Answer is A
Explanation
Choice A rationale
Reporting the client’s status to the healthcare provider is the appropriate action. The healthcare provider needs to be informed of the client’s death to provide further instructions and complete necessary documentation. This action ensures proper communication and adherence to protocols.
Choice B rationale
Asking the UAP to complete postmortem care is necessary, but it should be done after notifying the healthcare provider. The nurse must follow the proper sequence of actions to ensure all protocols are followed.
Choice C rationale
Beginning cardiopulmonary resuscitation (CPR) and calling a code is not appropriate because the client has a signed do not resuscitate (DNR) form. Performing CPR would go against the client’s wishes and legal documentation.
Choice D rationale
Notifying the family of the client’s death is important, but it should be done after reporting the client’s status to the healthcare provider. The healthcare provider may have specific instructions for communicating with the family and completing necessary documentation.