The nurse is admitting and preparing the client for surgery. Following administration of Ativan 2 mg orally, one time dose, which safety measure is most appropriate?
A) Place the client in a semi-Fowler's position.
B) Place the side rails in the up position.
C) Remove the water pitcher from the bedside.
D) Instruct the family to call for any client needs.
B
Feedback:
Ativan is a common hypnotic administered to reduce preoperative anxiety. The most appropriate safety measure is to limit the client's ability to get out of bed following administration of a preoperative sedative. Assistance is needed to maintain client safety. Placing the client in a semi-Fowler's position aids in gas exchange, but this is not indicated as a concern in this question and does not relate to a safety concern associated with this medication. Water should not be at the bedside for a client in the preoperative phase. Families can be helpful support for the client; however, it is the nurse's responsibility to maintain safety.
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