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 D
Explanation
Choice A rationale
Providing an opportunity for team members to ask questions is important for effective communication and teamwork, but it is not the primary action to verify the correct patient, procedure, and surgery. This action is more related to ensuring that all team members are on the same page and can clarify any doubts, but it does not directly verify the patient’s identity and procedure.
Choice B rationale
Discussing personal matters unrelated to the surgery is incorrect and unprofessional. It does not contribute to verifying the correct patient, procedure, and surgery. This action can lead to distractions and potential errors in patient care.
Choice C rationale
Reviewing the surgical instruments and equipment is important for ensuring that the necessary tools are available and functioning properly, but it does not directly verify the patient’s identity and procedure. This action is more related to the preparation and readiness of the surgical team.
Choice D rationale
Confirming the patient’s identity and procedure is the correct action to verify the correct patient, procedure, and surgery. This involves verifying the patient’s identity using at least two identifiers, confirming the procedure with the patient or their representative, and ensuring that the correct procedure is on the schedule. This step is crucial to prevent wrong-site, wrong- procedure, and wrong-patient surgeries.
Correct Answer is C
Explanation
Choice A rationale
Maintaining confidentiality of patient information is crucial, but it falls under the principle of confidentiality, not fidelity.
Choice B rationale
Remaining loyal and faithful to one’s personal beliefs and values is important, but it is not the primary focus of fidelity in nursing practice.
Choice C rationale
Upholding professional obligations and commitments is the essence of fidelity in nursing. It involves being faithful to the promises made to patients and the profession, ensuring trust and integrity in nursing practice.
Choice D rationale
Ensuring equitable distribution of healthcare resources is related to the principle of justice, not fidelity.
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