A nurse is about to administer an injection of an opioid medication to a patient. The nurse has drawn 1 mL of the medication from a 2 mL vial.
What should the nurse do next?

Choice A rationale

Carrying a patient’s soiled linens out of the room in a mesh linen bag is not the most effective way to prevent the spread of infection. While it’s important to handle soiled linens properly to avoid contaminating oneself or the environment, this action alone does not have a significant impact on preventing the spread of infection among a group of patients.

Choice B rationale

Placing a patient who has tuberculosis in a room with negative-pressure airflow is a key measure in preventing the spread of this airborne infection. Negative-pressure rooms prevent

contaminated air from escaping the room and spreading to other areas, thereby protecting other patients and healthcare workers.

Choice C rationale

Providing disposable plates and utensils for a patient who is HIV-positive is not necessary for preventing the spread of infection. HIV is not transmitted through casual contact or through sharing food or utensils.

Choice D rationale

Disposing of a patient’s blood-saturated dressing in a trash bag inside a second trash bag is a good practice for handling biohazardous waste, but it is not the most effective measure for preventing the spread of infection among a group of patients.

The correct answer is Choice C.

Choice C rationale: Assessing the patient for orthostatic hypotension is crucial because patients who can only bear weight on one leg may have compromised balance and stability. Orthostatic hypotension, or a sudden drop in blood pressure upon standing, could lead to dizziness or fainting, increasing the risk of falls and injury. Identifying this condition before transferring the patient ensures appropriate interventions can be taken to maintain safety and prevent accidents. The nurse can then apply necessary precautions such as additional support or slow, gradual position changes to minimize the risk.

Choice A rationale: Rocking the patient up to a standing position might help initiate the transfer, but it’s not the immediate priority after securing a safe environment. Ensuring the patient's stability and monitoring their vital signs, especially for orthostatic hypotension, is essential before attempting any movement.

Choice B rationale: Pivoting on the foot that is the farthest from the chair is part of the transfer technique, but it should only be performed after confirming the patient is stable and not at risk of orthostatic hypotension. Proper assessment precedes this step to prevent potential falls.

Choice D rationale: Applying a gait belt to the patient is important for safe transfer, but again, this step follows the assessment of the patient's condition. The gait belt is an aid for the transfer process, but its effectiveness relies on the patient's ability to stand without becoming dizzy or faint.