A nurse is caring for a client who has acute kidney injury. The client's ABGS are:

PH:7.26

PaCO2: 30 mm Hg

HCO3: 14 mEq/L

Which of the following acid-imbalances should the nurse identify the client is experiencing?

A) "If a client refuses a medication, you can place it in your pocket to administer later."
This statement is incorrect. Placing a medication in the pocket for later administration is not an appropriate practice and can lead to unauthorized possession and potential diversion of controlled substances. However, the second part of the statement, "You are required to have a second nurse witness disposal of a controlled substance," is correct.

B) "We use an automated dispensing device to track the use of controlled substances."
Automated dispensing devices are commonly used to track the administration and removal of controlled substances. This helps to ensure accountability and prevents diversion.

C) "Activities of the automated dispensing machine will be reviewed periodically."
Regular review of the activities of the automated dispensing machine helps to monitor for any discrepancies or irregularities in the handling of controlled substances, thus enhancing safety measures.

D) "We count the amount of a controlled substance available before removal from a medication drawer."
Counting the amount of controlled substance available before removal from a medication drawer is a crucial step in ensuring accurate inventory management and preventing unauthorized removal or diversion.

(A) Treatment: While treatment is an important part of the client’s information, it is typically included in the “Recommendation” component of ISBARR, where the nurse would discuss the recommended treatment plan.

(B) List of medications: The list of medications a client is taking is crucial information, but it is usually included in the “Background” component of ISBARR, which provides context about the client’s medical history and current medications.

(C) Medical condition: This is the most appropriate answer. The “Situation” component of ISBARR is meant to provide a brief overview of the client’s current situation, which includes their current medical condition or reason for admission.

(D) Vital signs: Vital signs are typically included in the “Assessment” component of ISBARR, where the nurse would discuss the results of their assessment of the client, including vital signs.