An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert and requests that no heroic measures be implemented if her breathing stops.
What actions should the nurse take first?

A. 3 mL syringe and a sterile needle.
This is incorrect. A sterile needle is unnecessary for administering an oral medication. Syringes with needles are used for injections, not for measuring or delivering oral medications.

B. One ounce medicine cup.
This is incorrect. While a medicine cup can be used for liquid medications, it is not precise for small volumes such as 2 mL. The graduations on a medicine cup are typically in larger increments, making it difficult to measure accurately.

C. 3 mL syringe.
This is correct. A 3 mL syringe is precise and suitable for measuring a 2 mL dose of a viscous liquid. Syringes provide clear markings, ensuring accurate measurement of small volumes. Additionally, the absence of a needle makes it appropriate for oral administration.

D. Tuberculin syringe.
This is incorrect. Although a tuberculin syringe can accurately measure small doses, it is designed for very small volumes, such as 1 mL or less. A 3 mL syringe is more appropriate for a 2 mL dose.

Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome.

In this case, the nurse should document the assessment that is not within normal limits, which is “Basilar lung sounds that are diminished in the left lung.”

Choice B is not the answer because contraction of the left pupil when light shines in the right eye is a normal finding known as consensual pupillary response.

Choice C is not the answer because capillary refill of 2 seconds in the lower right foot is a normal finding.

Choice D is not the answer because active bowel sounds in the lower right quadrant are a normal finding.