The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL. vial. Which action should the nurse perform with the remainder of the medication?

Withdraw the medication into a syringe and label it with the client's name.

Throw the vial into the trash in the presence of another nurse.

Place the vial with the remainder of the medication into a locked drawer.

Ask another nurse to witness the medication being discarded.

Answer and Explanation

The Correct Answer is D

A. Withdraw the medication into a syringe and label it with the client's name:

This is not necessary for the remainder of the medication. The medication should not be withdrawn into a syringe for future use or left labeled, as it could lead to errors or contamination.

B. Throw the vial into the trash in the presence of another nurse:

Discarding the vial into the trash is not appropriate, as it does not ensure proper documentation, accountability, or safe storage of the remaining medication. Additionally, the presence of another nurse does not address these concerns.

C. Place the vial with the remainder of the medication into a locked drawer:

While storing the vial in a locked drawer may prevent unauthorized access, it does not address the need for proper documentation and labeling of the remaining medication. Additionally, the vial should not be stored with the medication still in it after withdrawal.

D. Ask another nurse to witness the medication being discarded:

This is the appropriate action. Many facilities require that the disposal of unused or remaining medications, especially controlled substances, be witnessed by another nurse to ensure accountability and compliance with regulations.

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Correct Answer is C

Explanation

A. Initiate a fall risk protocol for the client:

Initiating a fall risk protocol may be premature based solely on observations of an upright posture and a smooth, steady gait. While falls are a significant concern in older adults, these observations suggest that the client currently exhibits good balance and mobility, which may not warrant immediate initiation of a fall risk protocol. Fall risk assessments typically involve a comprehensive evaluation of multiple factors beyond posture and gait, such as medical history, medications, cognitive status, and environmental factors.

B. Teach the client to shorten the stride to prevent falls:

Teaching the client to shorten their stride to prevent falls may not be necessary based on the observed smooth and steady gait. Shortening the stride is often recommended for individuals who exhibit signs of imbalance or instability during walking. However, in this scenario, the client demonstrates a smooth and steady gait, suggesting that their current gait pattern is effective and does not pose an immediate risk of falling.

C. Determine the client's activity tolerance:

Assessing the client's activity tolerance is an appropriate next step in the nursing process. While the observed upright posture and smooth, steady gait are positive indicators of mobility, understanding the client's overall activity tolerance provides valuable insight into their functional capacity and ability to perform activities of daily living safely. This assessment helps tailor care interventions to meet the client's individual needs and promotes optimal independence and quality of life.

D. Record the client's ability to perform ADLs safely:

Documenting the client's ability to perform activities of daily living (ADLs) safely is an essential component of nursing assessment and documentation. However, it may not be the most immediate action to take following the observation of an upright posture and smooth, steady gait. While documenting findings is important for maintaining accurate records and facilitating communication among healthcare team members, further assessment of the client's activity tolerance would provide additional context for documenting their functional status accurately.

A. Drink a mixture of warm water, whiskey, and honey at bedtime. B. Ask the healthcare provider for a mild sedative for bedtime. C. Avoid drinking caffeinated beverages late in the day. D. Take an afternoon nap to make up for missed sleep. E. Establish a regular time for going to bed and getting up.

Correct Answer is ["C","E"]

Explanation

A. Drink a mixture of warm water, whiskey, and honey at bedtime:

This suggestion is not appropriate as alcohol consumption close to bedtime can disrupt sleep patterns and exacerbate sleep problems. Additionally, alcohol can interact with medications and pose risks to health.

B. Ask the healthcare provider for a mild sedative for bedtime:

While medication may be prescribed for sleep disturbances in some cases, it should not be the first line of treatment, especially in older adults. Sedatives can have adverse effects and may lead to dependency if used long-term. Non-pharmacological interventions should be tried first.

C. Avoid drinking caffeinated beverages late in the day:

This is an appropriate suggestion. Caffeine is a stimulant that can interfere with sleep, so avoiding caffeinated beverages late in the day can help improve sleep quality.

D. Take an afternoon nap to make up for missed sleep:

While napping may be beneficial for some individuals, particularly if they are sleep deprived, it can worsen sleep difficulties in others, especially if taken late in the day. For individuals with insomnia or frequent nighttime awakenings, avoiding naps or limiting them to earlier in the day may be helpful.

E. Establish a regular time for going to bed and getting up:

This is an appropriate suggestion. Establishing a consistent sleep schedule helps regulate the body's internal clock and promotes better sleep quality. Going to bed and waking up at the same time each day, even on weekends, can help synchronize sleep-wake cycles and improve overall sleep patterns.

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The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL. vial. Which action should the nurse perform with the remainder of the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

Correct Answer is C

Explanation

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

Correct Answer is ["C","E"]

Explanation

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

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The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

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