The nurse is preparing a subcutaneous (SC) injection medication for an average-sized client.
The needle should be inserted at Select. degrees, and the skin should be Select.

Choice A rationale

A standing order is a pre-written medication order and protocol that applies to a specific patient population or clinical situation, allowing nurses to initiate treatment without immediate physician consultation. While it provides a framework, a daily medication is more specifically classified by its regular administration schedule, distinguishing it from general standing orders.

Choice B rationale

A routine order signifies a medication order that is carried out as prescribed until a discontinuation order or change is made. The medication is given on a regular, scheduled basis, often daily, multiple times a day, or weekly. This ensures consistent therapeutic levels for chronic conditions. Lasix 40 mg PO daily fits this description, as it is given consistently each day.

Choice C rationale

A STAT order (statim) means "immediately" and indicates that the medication must be administered as soon as possible, typically within 30 minutes of the order. This type of order is reserved for urgent situations where delay could significantly impact patient outcomes. Lasix ordered daily does not fall into this urgent category.

Choice D rationale

A PRN order (pro re nata) means "as needed.”. This type of order allows the nurse to administer medication based on the patient's symptoms or specific criteria rather than on a fixed schedule. Since Lasix is ordered "daily," it implies a fixed schedule, not an "as needed" administration.

Choice A rationale

Directly placing pills in a client's mouth with a gloved hand is generally not recommended as it can be perceived as invasive and may trigger the gag reflex, increasing the risk of aspiration. Client autonomy and active participation in medication administration are promoted for safety and adherence.

Choice B rationale

Tipping pills directly into a client's mouth can be problematic as it does not allow the client to assess the medication, potentially leading to discomfort or aspiration. It also bypasses the client's agency in the medication administration process, which is crucial for safety and compliance.

Choice C rationale

Offering the client the medication in their hand promotes autonomy and allows them to actively participate in the medication administration process. This approach respects client preferences, enhances safety by allowing self-administration, and facilitates the client's ability to examine the medication before ingestion, reducing the risk of errors.

Choice D rationale

Leaving medications unattended on a breakfast tray for later self-administration is a significant safety breach. This practice increases the risk of the medication being taken by another individual, loss or contamination, or incorrect timing of administration, potentially leading to adverse drug events. Direct observation of medication ingestion is essential.