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. Select the appropriate dressing: Although selecting the right dressing is essential, it is not the initial step.
B. Document the dressing change: Documentation follows the intervention, not precedes it.
C. Change the dressing: Performing the dressing change without adequate preparation is not the first step.
D. Review available dressing types: Reviewing available dressing options ensures appropriate selection based on the wound's condition and treatment goals.

A. Client 1 B. Client 2 C. Client 3 D. Client 4

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Client	Tag colour	Rationale
Client 1	Red	The significant blood loss and tourniquet application indicate immediate life-threatening injuries that are survivable with prompt intervention. The heart rate of 54/min is concerning for hypovolemic shock.
Client 2	Black	Fixed and dilated pupils, no pulse, and no spontaneous respirations indicate the client is deceased or has non-survivable injuries.
Client 3	Red	Disorientation, multiple lacerations with significant bleeding, and elevated heart and respiratory rates indicate hemodynamic instability requiring immediate intervention.
Client 4	Yellow	The client is stable, with a suspected arm fracture and minor abrasions. Treatment can be delayed without significant risk of deterioration.

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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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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has a stage III pressure ulcer and requires a dressing change. Which of the following steps should the nurse take first?

Correct Answer is D

Explanation

The nurse is assisting in the care of clients during a mass casualty event. Exhibits For each client, click to specify if the client should be assigned a red. yellow, or black tag. A tag color may be assigned to more than one client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

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