A nurse is preparing to administer lorazepam 0.044 mg/kg IV bolus to a client who weighs 50 kg (110 lb). The amount available is lorazepam injection 4 mg/mL How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Choice A reason: A new onset of weakness requires nursing assessment because it could indicate an acute change in condition such as stroke, electrolyte imbalance, or infection. Delegating vital signs in this case would be unsafe, as the nurse must perform a thorough assessment and determine appropriate interventions.

Choice B reason: A client requesting pain medication 2 days after surgery is stable enough for the AP to measure vital signs. This task is appropriate to delegate because the nurse can then use the vital signs to evaluate the client’s status before administering pain medication. The nurse retains responsibility for interpreting the results and deciding on medication administration, but the AP can safely collect the data.

Choice C reason: A new onset of chest pain is a potentially life-threatening emergency that requires immediate nursing assessment and intervention. Delegating vital signs in this situation would delay critical care. The nurse must personally assess the client, obtain vital signs, and initiate emergency protocols if necessary.

Choice D reason: A client transferring to the intensive care unit is unstable and requires close monitoring. The nurse must perform a comprehensive assessment and obtain vital signs themselves to ensure accurate evaluation before and during transfer. Delegating this task would be inappropriate because of the client’s critical condition.

Choice A reason: Reporting suspected abuse to Adult Protective Services is the nurse’s legal and ethical responsibility. Visible contusions on all extremities raise concern for physical abuse, and mandatory reporting laws require healthcare providers to notify protective services to ensure client safety. This is the correct action.

Choice B reason: Interviewing the client with the adult child present is inappropriate because it may prevent the client from speaking honestly about the situation. The presence of a potential abuser can inhibit disclosure and compromise assessment accuracy.

Choice C reason: Telling the client they must answer every Question is coercive and violates patient autonomy. Clients have the right to refuse to answer questions, and forcing responses is non-therapeutic.

Choice D reason: Advising the client to consult a social worker is supportive but insufficient. While social workers provide resources and counseling, the priority action is mandatory reporting to ensure immediate safety.