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AIM The aim of this study was to understand how acute care nurses make decisions about administering "as needed" (PRN) psychotropic medications to hospitalized people with dementia. BACKGROUND Behavioral and psychological symptoms of dementia occur in approximately 75% of people with dementia admitted to acute care. Despite this, few studies provide insight into the use and prevalence of psychotropic use in acute care. DESIGN A qualitative descriptive design was used to explore acute care nurses' decision making about PRN psychotropic medication administration to people with dementia. METHODS Semi-structured interviews were conducted with eight nurses from three acute care medical units in a large tertiary hospital in Western Canada. Conventional content analysis was used to develop three themes that reflect nurses' decision-making related to administering PRNs to hospitalized people with dementia. COREQ guidelines were followed. RESULTS Three themes of legitimizing control, making the patient fit and future telling were developed. Legitimizing Control involved medicating undesirable behaviors to promote the nurses' perceptions of safety. Making the Patient Fit involved maintaining routine and order. Future Telling involved pre-emptively medicating to prevent undesirable behaviors from escalating. Nurses provided little to no mention of assessing for physical causes contributing to behaviors. PRNs were seen as a reasonable alternative to physical restraints and were frequently used. Additionally, organizational and unit routines greatly influenced nurses' decision-making. CONCLUSIONS These findings provide an initial understanding into how nurses make decisions to administer PRN medications to hospitalized older people and may inform prescribing practices. There were novel findings about the lack of assessment prior to PRN administration, and the nurses' collective response in decision-making. More research is needed to better understand the complexities of nurses' decision-making, to assist in the development of interventions for nursing practice.