A nurse has completed the planning step of the nursing process for a client who has an acid-base imbalance. Which of the following steps should the nurse take next?

Explanation:

A. "We use an automated dispensing device to track the use of controlled substances."

This is a valid statement. Automated dispensing devices (ADDs) help track the use of controlled substances by requiring users to log in, record transactions, and provide an audit trail of medication access.

B. "You are required to have a second nurse witness disposal of a controlled substance."

Having a second nurse witness disposal of controlled substances is a common practice to ensure accountability and prevent diversion. This statement aligns with safety protocols.

C. “If a client refuses a medication, you can place it in your pocket to administer later."

This statement is incorrect and potentially dangerous. Controlled substances should never be pocketed or carried around for later administration, as this increases the risk of diversion and compromises medication safety.

D. "Activities of the automated dispensing machine will be reviewed periodically."

Reviewing the activities of the automated dispensing machine is an essential part of medication safety and helps detect any discrepancies or irregularities in medication access and administration.

E. "We count the amount of a controlled substance available before removal from a medication drawer."

Counting the amount of controlled substances before removal from a medication drawer is a standard procedure to ensure accurate inventory management and detect any discrepancies or losses promptly.

Explanation:

A. Incorporate the treatment into the client's care:

Once the nurse has determined whether the client's grieving is healthy or complicated, they can integrate appropriate treatments and interventions into the client's care plan. Treatment options may include counseling, therapy, support groups, medication (if indicated), and holistic approaches to address physical, emotional, and spiritual aspects of grief.

B. Develop client-specific goals and outcomes:

Collaborating with the client, the nurse establishes client-specific goals and outcomes related to grief management and coping. These goals should be realistic, measurable, and aligned with the client's needs and preferences. Examples of goals may include improving coping skills, reducing emotional distress, fostering acceptance, and promoting resilience.

C. Determine whether coping strategies were successful:

Throughout the care process, the nurse continuously evaluates the effectiveness of coping strategies implemented to support the client in managing grief. Assessment of coping strategies involves monitoring the client's emotional state, functional status, coping skills utilization, and progress toward achieving established goals and outcomes. Adjustments to the care plan may be made based on the assessment findings.

D. Establish whether the client's grieving is healthy or complicated:

This step involves assessing the client's grief to determine whether it is a normal, healthy response to loss or if it has become complicated, characterized by intense, prolonged, or dysfunctional grief reactions. Assessing the client's grief status is crucial for tailoring appropriate interventions and support.