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 A
Explanation
Choice A rationale
Any competent adult regardless of age or health status can create an advance directive. Advance directives are legal documents that allow individuals to specify their preferences for medical care in case they become unable to communicate their wishes. Competence is the key requirement, meaning the individual must be able to understand and make decisions about their medical care.
Choice B rationale
Only individuals with terminal illnesses is incorrect. While individuals with terminal illnesses may benefit from having an advance directive, it is not a requirement. Advance directives are available to any competent adult, regardless of their health status.
Choice C rationale
Only individuals over the age of 65 is incorrect. Advance directives can be created by any competent adult, regardless of age. It is important for all adults to consider having an advance directive to ensure their medical preferences are known and respected.
Choice D rationale
Only individuals with chronic medical conditions is incorrect. While individuals with chronic medical conditions may benefit from having an advance directive, it is not a requirement.
Advance directives are available to any competent adult, regardless of their health status.
Correct Answer is D
Explanation
Choice A rationale
Following the order as prescribed without clarification can lead to errors if the order is unclear or incomplete.
Choice B rationale
Administering the medication at a later time without clarification can also lead to errors and may delay necessary treatment.
Choice C rationale
Disregarding the order and seeking approval from another physician is not appropriate. The nurse should seek clarification from the ordering physician.
Choice D rationale
Asking the physician to clarify the dosage and route ensures that the order is accurate and complete, reducing the risk of medication errors.
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