A nurse is caring for a client who has refused medications. Which of the following actions should the nurse take? (Select all that apply.)

Document the client's statement in the medical record.

Reinforce teaching about the purposes of the medications.

Tell the client they can take their medications later in the day.

Record non administration in the client's medication administration record.

Inform the pharmacy the client's medications will be wasted.

Answer and Explanation

Correct Answer : A,B,D

A.   Document the client's statement in the medical record. Accurate documentation is essential to provide a complete record of the client's care and decisions.
B.   Reinforce teaching about the purposes of the medications. Providing information can help the client make informed decisions and reconsider their refusal.
C.   Tell the client they can take their medications later in the day. This may not be appropriate, depending on the medication schedule and therapeutic requirements.
D.   Record non-administration in the client's medication administration record (MAR). This ensures an accurate medication history and alerts other providers to the missed dose.
E.   Inform the pharmacy the client's medications will be wasted. Medications are not automatically wasted upon refusal; they can often be returned or rescheduled.

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Correct Answer is D

Explanation

A. Cover the site with a stockinette dressing: This action may help secure the IV site but does not immediately address the safety concern.
B. Administer a sedative: Administering sedatives is not the first-line intervention and requires a provider's order.
C. Apply a soft mitten restraint: Restraints should be the last resort after implementing less restrictive measures. Closer observation and attempts to redirect the client are less restrictive and should be tried first.
D. Place the client close to the nurses' station: Proximity allows for frequent monitoring, preventing further self-harm.

A. Weigh the client every other day. B. Place the client in a supine position. C. Encourage the client to ambulate three times per day. D. Report urine output less than 30 mL/hr.

Correct Answer is D

Explanation

A. Weigh the client every other day. Daily weights are essential for monitoring fluid retention in pulmonary edema.
B. Place the client in a supine position. The client should be placed in a high Fowler's position to improve lung expansion and reduce dyspnea.
C. Encourage the client to ambulate three times per day. Clients with pulmonary edema are often too compromised to ambulate frequently. Rest is initially preferred.
D. Report urine output less than 30 mL/hr. Low urine output may indicate decreased renal perfusion, fluid retention, or worsening heart failure, all of which require prompt reporting.

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A nurse is caring for a client who has refused medications. Which of the following actions should the nurse take? (Select all that apply.)

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