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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Urinating after the specimen collection is incorrect. While it's important to ensure urine doesn't contaminate the stool specimen during collection, the instruction to urinate after the collection doesn't directly impact the collection process itself. The primary focus is on avoiding contamination of the stool sample with urine or toilet tissue during collection.
Choice B Reason:
Placing 1.3 cm (0.5 in) of formed stool into a culture tube is incorrect. The amount of stool needed for a specimen can vary based on the specific test requirements or laboratory instructions. A fixed measurement, like 1.3 cm of formed stool, might not accurately represent the necessary quantity for all types of stool tests. Specific instructions from the healthcare provider or laboratory should be followed for proper collection.
Choice C Reason:
Keeping the specimen in a warm area is incorrect. Stool specimens are typically collected and stored at room temperature unless otherwise specified by specific test instructions. Placing the specimen in a warm area could alter the characteristics of the sample or promote bacterial growth, potentially affecting test accuracy. The specimen should be handled according to the specific requirements outlined for the particular test.
Choice D Reason:
Avoid placing toilet tissue in the bedpan after defecation is correct. Placing toilet tissue in the bedpan after defecation can contaminate the stool specimen, affecting the accuracy of test results. It's important to collect the stool sample without any contamination from toilet tissue or urine.
Correct Answer is A
Explanation
Choice A Reason:
This is the correct action. A filter needle should be used when drawing medication from an ampule to prevent glass particles from being aspirated into the syringe and subsequently administered to the patient.
Choice B Reason:
Adding 0.5 ml of diluent to the medication is incorrect. Adding diluent to medication from an ampule is not a standard practice. Ampules usually contain pre-measured doses of medication and are designed for direct withdrawal without dilution. Adding diluent could alter the concentration and effectiveness of the medication.
Choice C Reason:
This is not necessary. Once the ampule is opened, it should be handled with care to avoid contamination, but cleansing the tip with an alcohol swab is not a standard practice since it does not effectively remove glass particles.
Choice D Reason:
This is incorrect. Ampules are not pressurized containers, and injecting air into an ampule is unnecessary and could cause the medication to spill out or create bubbles that interfere with accurate dosing.
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