A nurse is preparing to administer Valium 10 mg PO at bedtime. The amount available is Valium 5 mg tablets.

How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies.

(Do not use a trailing zero)

Choice A rationale
Loosening the restraints and assessing the patient’s skin is important, but it should be done as part of a regular assessment and not as the first action. The nurse should first document the findings to ensure accurate and timely communication of the patient’s condition.
Choice B rationale
Documenting the findings in the patient’s chart is the correct action. Accurate documentation is essential for communicating the patient’s condition and any interventions performed. It ensures continuity of care and provides a legal record of the patient’s status and the care provided.
Choice C rationale
Continuing to monitor the patient without making any changes is not appropriate. The nurse should assess the patient’s condition and document the findings to ensure that any necessary interventions are performed promptly.
Choice D rationale
Applying ice packs to reduce swelling is not appropriate in this context. The nurse should first document the findings and then assess the need for any interventions based on the patient’s condition.

Choice A rationale
A client who has dysphagia should be seen first because dysphagia can lead to serious complications such as aspiration, choking, and pneumonia. Immediate assessment and intervention are necessary to ensure the client’s airway is protected and to prevent potential respiratory distress.
Choice B rationale
A client who asks about community resources is important, but this is not an urgent need. This client can be seen after addressing more immediate clinical concerns.

Choice C rationale
A client who will require oxygen at home needs proper planning and education, but this can be addressed after ensuring the immediate safety of clients with urgent needs.
Choice D rationale
A client who wants a priest to visit while they are in the hospital is a valid request, but it is not an urgent clinical need. This can be arranged after addressing clients with more immediate health concerns.