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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should first identify the impact of the mastectomy on the client’s body image.
This is because the client’s behavior of avoiding looking at her dressings and being tearful suggests that she may be struggling with changes to her body image after the surgery.
By identifying and addressing this issue, the nurse can provide appropriate emotional support and interventions to help the client cope with these changes.
Choice A is not the first action the nurse should take because referring the client to a breast cancer support group may be helpful, but it is not addressing the immediate concern of the client’s emotional state.
Choice C is not the first action because encouraging the client to assist with her dressing changes may be premature if she is still struggling emotionally with her body image.
Choice D is not the first action because providing the client with a mirror to look at her mastectomy incisions may be overwhelming for her if she is not yet ready to confront her changed appearance.
Correct Answer is C
Explanation
When caring for a client who has wrist restraints after an episode of violent behavior, the nurse should remove one restraint at a time.
This allows the nurse to assess the client’s behavior and response to having one arm free while still maintaining some level of control and safety.
Choice A is wrong because tying the restraints to the side rail can be dangerous as it can cause injury to the client if they move suddenly.
Choice B is wrong because removing the restraints every 3 hours is not a specific guideline and may vary depending on the facility’s policy and the client’s condition.
Choice D is wrong because securing restraints with a square knot can make it difficult to quickly release the restraints in an emergency.
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