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?
Ask another nurse to observe the medication wastage.
Notify the pharmacy when wasting the medication.
Lock the remaining medication in the controlled substances cabinet.
Dispose of the vial with the remaining medication in a sharps container.
The Correct Answer is A
Choice A rationale
After drawing up the medication, the nurse should ask another nurse to observe the medication wastage. This is a standard procedure for controlled substances like opioids. The second nurse acts as a witness to ensure that the unused portion of the medication is disposed of properly and not diverted for inappropriate use.
Choice B rationale
Notifying the pharmacy when wasting the medication is not the immediate next step after drawing up the medication. While some institutions may require notification of the pharmacy for controlled substance wastage, the immediate next step is typically to have another nurse witness the wastage.
Choice C rationale
Locking the remaining medication in the controlled substances cabinet is not the immediate next step after drawing up the medication. The remaining medication should be wasted with a witness present.
Choice D rationale
Disposing of the vial with the remaining medication in a sharps container is not the immediate next step after drawing up the medication. The remaining medication should be wasted with a witness present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Hypertension refers to high blood pressure, which is not directly indicated by the given vital signs.
Choice B rationale
Hypotension, or low blood pressure, is also not directly indicated by the provided vital signs.
Choice C rationale
Tachycardia refers to a fast heart rate. If the patient’s heart rate increased significantly between 0800 and 0815, this could be a sign of tachycardia.
Choice D rationale
Bradycardia, or a slow heart rate, would be indicated by a decrease in heart rate, which is not suggested by the given information.
Correct Answer is B
Explanation
Choice A rationale
The client was admitted three days ago. This statement is factual, but it does not directly address the current condition of the client’s pressure injury. The time of admission is not as relevant as the progression and treatment of the wound. Therefore, while this choice is accurate, it is not the most critical piece of information in this context.
Choice B rationale
The pressure injury was at stage 4. This is the correct answer. Stage 4 pressure ulcers involve full-thickness skin loss potentially extending into the subcutaneous tissue layer. Stage 4 pressure ulcers extend even deeper, exposing underlying muscle, tendon, cartilage or bone.
The presence of slough, eschar, and tunnels, as well as the size of the wound, are consistent with a stage 4 pressure ulcer. The treatment provided, including debridement and negative
pressure wound therapy, is also typical for this stage of pressure injury. Therefore, this choice accurately describes the client’s condition.
Choice C rationale
The client reported pain as a 2 on a scale from 0 to 10. While it’s important to monitor the client’s pain levels, this information alone does not provide a comprehensive understanding of the client’s condition. Pain can be subjective and varies from person to person. A score of 2 indicates minor pain, which is manageable and does not significantly interfere with the client’s daily activities. However, this does not negate the severity of a stage 4 pressure injury.
Choice D rationale
The dressing was reapplied and sealed. This statement describes one aspect of the wound care process. Negative pressure wound therapy involves the application of a vacuum through a special sealed dressing. The dressing is crucial in creating a moist healing environment, reducing edema, and promoting wound healing. However, the reapplication and sealing of the dressing alone do not provide a complete picture of the client’s condition or the severity of the pressure injury.
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