The practical nurse (PN) is preparing cefazolin 400 mg IM for a client with a gram-positive infection. The available vial is labeled, "Cefazolin 1 gram," and the instructions for reconstitution state, for IM use, add 2 mL sterile water for injection. Total volume after reconstitution is 2.5 mL. After reconstitution, how many mL should be administered to the client? (Enter numeric value only. If rounding is required, round to the whole number, nearest tenths/hundredth).

Choice A rationale:

Review the client's serum calcium level. Rationale: Checking the client's serum calcium level is not the most appropriate action in this situation. Hand and finger spasms during blood pressure measurement are more likely due to discomfort or muscle tension than a calcium deficiency. There is no immediate indication that the client's calcium level needs to be assessed urgently.

Choice B rationale:

Administer an as-needed (PRN) antianxiety medication. Rationale: Administering an antianxiety medication is not indicated in this situation. The client's symptoms of hand and finger spasms during blood pressure measurement are not likely related to anxiety. It is essential to address the immediate issue of obtaining an accurate blood pressure reading.

Choice C rationale:

Ask the UAP to take the blood pressure in the other arm. Rationale: This is the correct answer. When the UAP reports spasms in the client's right hand and fingers while taking blood pressure using the same arm, the nurse should prioritize obtaining an accurate blood pressure measurement. Asking the UAP to use the other arm can help ensure a more reliable reading. Muscle spasms in the arm being used for blood pressure measurement can lead to inaccurate results.

Choice D rationale:

Tell the UAP to use a different sphygmomanometer. Rationale: In this scenario, the issue appears to be related to muscle spasms in the client's hand and fingers rather than the sphygmomanometer itself. Changing the sphygmomanometer is unlikely to resolve the problem. The priority is to obtain an accurate blood pressure reading by addressing the spasms in the arm being used.

The correct answer is Choice A.

Choice A rationale: In emergencies where immediate surgery is required to save a life, implied consent is assumed if the patient is unresponsive and no family is available. Ethical and legal guidelines allow proceeding without signed consent to avoid delays that could be life-threatening.

Choice B rationale: A close friend typically does not have legal authority to provide informed consent for medical procedures unless they have been designated as a healthcare proxy. Therefore, this action would not be legally appropriate in this situation.

Choice C rationale: Seeking an emergency court order for surgery could cause delays that are detrimental to the patient's health. In life-threatening situations, implied consent is sufficient, and prompt action is necessary to save the patient's life.

Choice D rationale: Continuing to provide life support without proceeding with surgery may not be sufficient to address the life-threatening condition. Immediate surgical intervention is necessary, and implied consent allows this to be done without waiting for a guardian.