A nurse is caring for a client. The client states, "I don't want to take any medication.”. Which of the following actions should the nurse take?
Tell the client the physician wants the client to take the medicine.
Explain the purpose for the medication.
Ask the client why they are being difficult.
Document that the client refuses the medication.
The Correct Answer is D
Choice A rationale:
Telling the client that the physician wants them to take the medicine may not address the client’s concerns or fears about the medication.
Choice B rationale:
Explaining the purpose of the medication is important, but it does not directly address the client’s refusal.
Choice C rationale:
Asking the client why they are being difficult could escalate the situation and is not a respectful or therapeutic response.
Choice D rationale:
Documenting that the client refuses the medication is the most appropriate action as it accurately records the client’s decision and can inform future care planning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Checking the medication at the nurses’ station does not ensure that the right medication is given to the right client.
Choice B rationale:
Checking the medication at the client’s bedside ensures that the right medication is given to the right client.
Choice C rationale:
Checking the medication at the time of documentation is too late to prevent medication errors.
Choice D rationale:
Checking the medication in the area where the nurse obtained the medication does not ensure that the right medication is given to the right client.
Correct Answer is D
Explanation
Choice A rationale:
Increased thirst is not a specific sign of congestive heart failure.
Choice B rationale:
A rise in blood pressure is not a specific sign of congestive heart failure.
Choice C rationale:
Dizziness when standing up too quickly could be a sign of orthostatic hypotension, not specifically congestive heart failure.
Choice D rationale:
Weight gain of 2 lbs or more in 24 hours could indicate fluid retention, a common sign of congestive heart failure.
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