The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL. vial. Which action should the nurse perform with the remainder of the medication?

Withdraw the medication into a syringe and label it with the client's name.

Throw the vial into the trash in the presence of another nurse.

Place the vial with the remainder of the medication into a locked drawer.

Ask another nurse to witness the medication being discarded.

Answer and Explanation

The Correct Answer is D

A. Withdraw the medication into a syringe and label it with the client's name:

This is not necessary for the remainder of the medication. The medication should not be withdrawn into a syringe for future use or left labeled, as it could lead to errors or contamination.

B. Throw the vial into the trash in the presence of another nurse:

Discarding the vial into the trash is not appropriate, as it does not ensure proper documentation, accountability, or safe storage of the remaining medication. Additionally, the presence of another nurse does not address these concerns.

C. Place the vial with the remainder of the medication into a locked drawer:

While storing the vial in a locked drawer may prevent unauthorized access, it does not address the need for proper documentation and labeling of the remaining medication. Additionally, the vial should not be stored with the medication still in it after withdrawal.

D. Ask another nurse to witness the medication being discarded:

This is the appropriate action. Many facilities require that the disposal of unused or remaining medications, especially controlled substances, be witnessed by another nurse to ensure accountability and compliance with regulations.

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Correct Answer is ["B","C","E"]

Explanation

A. Use standard precautions and wear a mask.

While standard precautions should always be followed to prevent the spread of infection, wearing a mask is not specifically indicated for MRSA unless there is a risk of respiratory transmission. Contact precautions are more appropriate for MRSA.

B. Institute contact precautions for staff and visitors.

Contact precautions are necessary to prevent the spread of MRSA, a highly contagious bacteria. This involves using gloves and gowns when entering the client's room to prevent transmission of the bacteria to others.

C. Send wound drainage for culture and sensitivity.

Culturing the wound drainage helps identify the specific bacteria causing the infection and determines the most effective antibiotics for treatment (sensitivity testing).

D. Explain the purpose of a low bacteria diet.

A low bacteria diet is not typically indicated for managing MRSA infections. Instead, the focus should be on wound care, antibiotic therapy, and infection control measures to address the MRSA infection.

E. Monitor the client's white blood cell count.

Monitoring the white blood cell count helps assess the client's immune response and the severity of the infection. Elevated white blood cell counts may indicate an active infection and the need for further intervention.

A. Document the absence of the radial pulse. B. Release the manometer valve immediately. C. Inflate blood pressure cuff to 120 mm Hg. D. Record a palpable systolic pressure of 90 mm Hg.

Correct Answer is C

Explanation

A. Document the absence of the radial pulse:

While it's important to document findings accurately, it's also crucial to ensure that blood pressure measurements are obtained correctly. If the radial pulse becomes unpalpable before reaching the expected systolic pressure, further action is needed to obtain an accurate measurement.

B. Release the manometer valve immediately:

Releasing the manometer valve immediately would lead to deflating the cuff and potentially missing the opportunity to obtain an accurate blood pressure measurement. This action is not appropriate at this stage.

C. Inflate blood pressure cuff to 120 mm Hg:

When the radial pulse becomes unpalpable during cuff inflation, it indicates that the cuff pressure is above the systolic pressure. To accurately determine the systolic pressure, the cuff should be inflated to a higher pressure (usually 20-30 mm Hg above the point where the radial pulse disappears) and then slowly deflated while palpating for the return of the radial pulse.

D. Record a palpable systolic pressure of 90 mm Hg:

If the radial pulse is no longer palpable at 90 mm Hg, this suggests that the true systolic pressure is higher than 90 mm Hg. Recording a palpable systolic pressure of 90 mm Hg without further action would likely underestimate the true systolic pressure.

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The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL. vial. Which action should the nurse perform with the remainder of the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is paraplegic is admitted with a foul smelling drainage from a sacral ulcer. The client is suspected to have a methicillin resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

Correct Answer is C

Explanation

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