A nurse is assessing a client’s understanding of their medication regimen. The client nods in agreement but does not respond verbally. What is the nurse’s best action?
Assume the client understands and proceed with the regimen.
Repeat the instructions using different words.
Document that the client has full understanding of the regimen.
Ask the client to verbally respond to the Questions.
The Correct Answer is D
Choice A rationale
Assuming the client understands and proceeding with the regimen is incorrect. It does not verify the client’s understanding and could lead to non-compliance or errors in medication administration.
Choice B rationale
Repeating the instructions using different words may help, but it does not ensure that the client has understood the information. It is important to verify understanding through the client’s response.
Choice C rationale
Documenting that the client has full understanding of the regimen without verification is incorrect. It assumes understanding without confirmation, which could lead to potential errors.
Choice D rationale
Asking the client to verbally respond to the questions is the best action. It ensures that the client has understood the information and allows the nurse to clarify any misunderstandings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Step 1 is to determine the number of tablets needed. 10 mg ÷ 5 mg/tablet = 2 tablets The nurse should administer 2 tablets per dose.
Correct Answer is C
Explanation
Choice A rationale
A 5-year-old patient admitted yesterday with pneumonia may require frequent assessments and interventions that are within the scope of practice for an LPN. However, the complexity of care for a newly admitted patient with a potentially unstable condition may be better suited for an RN.
Choice B rationale
A 78-year-old female with osteoporosis who needs assistance performing range of motion exercises and ambulating with a walker can be managed by an LPN. These tasks are within the LPN’s scope of practice and do not require the higher level of assessment and decision-making skills of an RN.
Choice C rationale
A 78-year-old patient newly admitted with congestive heart failure requires complex assessments, monitoring, and interventions that are within the scope of practice for an RN. The RN’s advanced skills and knowledge are necessary to manage the patient’s condition effectively.
Choice D rationale
A 34-year-old patient post knee arthroscopy who requires reinforced crutch walking can be managed by an LPN. These tasks are within the LPN’s scope of practice and do not require the higher level of assessment and decision-making skills of an RN.
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