A nurse is preparing to administer a controlled substance to a client for pain management.

Which of the following actions should the nurse take?

Verify the count total of the controlled substance after removing the amount needed.

Place the wasted portion of the controlled substance in the sharps container.

Report any discrepancy in the count total of the controlled substance after administration.

Ask a second nurse to record her signature when wasting any unused portion of the controlled substance.

Answer and Explanation

The Correct Answer is D

Ask a second nurse to record her signature when wasting any unused portion of the controlled substance.
This is because if a controlled substance is wasted, this waste must be witnessed by and documented by the wasting nurse and another nurse.
Choice A is wrong because the count total of the controlled substance should be verified before removing the amount needed, not after.
Choice B is wrong because the wasted portion of the controlled substance should not be placed in the sharps container.
It should be disposed of according to facility/agency policy.
Choice C is wrong because any discrepancy in the count total of the controlled substance should be reported immediately, not after administration 1.

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Correct Answer is A

Explanation

Secure the tracheostomy ties to allow one finger to fit snugly underneath. This is important to ensure that the tracheostomy tube is secure and in place.

Choice B is wrong because normal saline is not typically used to cleanse the skin around the stoma.

Choice C is wrong because soaking the outer cannula in warm, soapy tap water is not a recommended method of cleaning.

Choice D is wrong because a cotton tip applicator should not be used to clean inside the inner cannula.

A. 620 mL. B. 460 mL. C. 520 mL. D. 440 mL.

Correct Answer is D

Explanation

Step 1: Calculate the total fluid intake. The client received 0.9% sodium chloride 600 mL IV infusion and cefazolin 250 mg in dextrose 5% in water 100 mL intermittent IV bolus. So, the total fluid intake is 600 mL + 100 mL = 700 mL.

Step 2: Calculate the total fluid output. The client had 200 mL emesis, 40 mL voided urine, and 20 mL urine from straight catheterization. So, the total fluid output is 200 mL + 40 mL + 20 mL = 260 mL.

Step 3: Calculate the net fluid intake. The net fluid intake is the total fluid intake minus the total fluid output. So, the net fluid intake is 700 mL - 260 mL = 440 mL.

Therefore, the nurse should record the net fluid intake as 440 mL.

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A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

How should the nurse record the net fluid intake for a client who received 0.9% sodium chloride 600 mL IV infusion, cefazolin 250 mg in dextrose 5% in water 100 mL intermittent IV bolus, 200 mL emesis, 40 mL voided urine, and 20 mL urine from straight catheterization?

Correct Answer is D

Explanation

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A nurse is preparing to administer a controlled substance to a client for pain management.

Which of the following actions should the nurse take?