A nurse is caring for a client who is terminally ill and has a do-not-resuscitate order on his medical record. The client asks, "What should I do if I have difficulty breathing?" Which of the following responses should the nurse make?

A. A family member is napping in the client's room.

This situation, while not ideal, doesn't involve harm or potential harm to a client, staff, or visitor. It may be addressed through communication and policy reminders but may not require an incident report.

B. A client refuses to eat at mealtime.

Client refusal to eat, while concerning, is not an unexpected or unusual event. It is a common aspect of care, and incident reports are not typically used for such situations.

C. A client's bed alarm is malfunctioning.

This situation involves a malfunction in equipment designed to ensure client safety. It has the potential to compromise the safety of the client and may require an incident report to document the issue and address it appropriately.

D. An assistive personnel is late for the upcoming shift.

Lateness may be an issue that needs addressing, but it's not typically considered an incident requiring a formal incident report. This situation may be addressed through workplace policies and communication.

Choice A Reason:

Discarding the vial with the remaining medication in the sharp container is inappropriate. This would result in unnecessary waste of the medication and could lead to increased healthcare costs.

Choice B Reason:

Having another nurse witness the disposal of the remaining medication is inappropriate. Witnessing the disposal is typically required for controlled substances, but in this situation, it's more appropriate to use the remaining medication with appropriate documentation.

Choice C Reason:

Drawing up the remaining 1 mg in a syringe and label it with the contents, date, and time is appropriate. This approach minimizes medication wastage and allows for appropriate documentation of the extra dose drawn up. However, it is crucial to label the syringe clearly with the contents, date, and time to avoid any potential errors or confusion. This labeled syringe can then be used for subsequent doses, as long as it remains within the medication's expiration period and adheres to institutional policies.

Choice D Reason:

Storing the vial in the client's medication drawer for future use is inappropriate. Keeping the vial for future use without appropriate documentation is not recommended, as it may lead to medication errors or confusion.