A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, "I'm not going to take this medication because it makes me sick and dizzy." Which of the following actions should the nurse take first?
Document the refusal in the client's medical record.
Return the medication to the medication cabinet.
Inform the client of the potential consequences of their refusal.
Notify the provider of the client's refusal.
The Correct Answer is C
Choice A Reason:
While documenting the refusal is important for accurate record-keeping and to ensure communication among the healthcare team, addressing the client's immediate concerns and attempting to resolve the issue of medication refusal should take precedence before documenting.
Choice B Reason:
Returning the medication is a procedural step but is not the immediate action needed when a client refuses medication due to adverse effects. First, it's important to address the client's concerns and discuss the potential consequences of refusal.
When a client refuses medication due to experiencing adverse effects, the initial action for the nurse to take is:
Choice C Reason:
Inform the client of the potential consequences of their refusal is correct. It's essential to engage in a conversation with the client to understand their concerns and educate them about the potential consequences of not taking their antihypertensive medication. The nurse should discuss the risks associated with untreated high blood pressure to ensure the client is informed about the importance of the prescribed medication.
Choice D Reason:
Notifying the provider is important, but it is generally done after the nurse has attempted to address the client’s concerns and informed them of the consequences. The provider should be informed if the refusal persists or if the nurse believes the situation requires further medical intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
"Encourage your partner to eat three large meals each day." Is incorrect. At the end of life, a patient's appetite might decrease, and they may not tolerate large meals. Encouraging large meals can cause discomfort or be inappropriate for their condition.
Choice B Reason:
"We will use an electric blanket to keep your partner warm." Is incorrect. While maintaining comfort is important, the use of an electric blanket might not be suitable as the patient's circulation and ability to regulate body temperature might be compromised.
Choice C Reason:
"Opioids will be restricted if your partner develops respiratory distress." Is incorrect.
Opioids can be appropriate for managing symptoms like pain or dyspnea at the end of life. Restricting opioids solely due to the risk of respiratory distress might hinder adequate symptom management. The use of opioids should be based on individual patient needs and careful assessment by healthcare providers.
Choice D Reason:
"Assume your partner can hear you, even if they do not respond." Is correct. This statement encourages communication and acknowledges the possibility that the patient might still be able to perceive their surroundings, even if they are not responsive. It supports the importance of providing emotional support and communication during the end-of-life process.
Correct Answer is C
Explanation
Choice A Reason:
"The sides of the sling are for the client to hold on to." Is inaccurate. The sides of the sling in a mechanical lift are typically designed for the lift's attachment points, not for the client to hold on to. Clients usually need to remain relaxed and may not be able to hold on during the transfer.
Choice B Reason:
"The lower end of the sling goes below the client's calves." Is inaccurate. While it's important to position the sling correctly, stating that the lower end goes below the client's calves might not be universally accurate. The placement of the sling would depend on the type of lift and the specific needs of the client. It's crucial to follow manufacturer instructions and individualized care plans for sling placement.
Choice C Reason:
"This type of device is used for a client who cannot assist." Is accurate. This statement correctly identifies the primary purpose of a mechanical lift, which is to assist individuals who are unable to bear weight or assist with movement due to physical limitations. The mechanical lift helps transfer individuals safely without relying on their own strength or ability to assist in the movement.
Choice D Reason:
"The device requires the client to use upper body strength." Is inaccurate. This statement is incorrect. The purpose of a mechanical lift is to assist clients who cannot use their own strength, especially those who cannot bear weight or assist with movement. It is the machine that aids in lifting and transferring the individual, not the client's strength.
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