A nurse is caring for an older adult client who has a hearing aid.Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?

Choice A rationale

Administering vaginal cream is a medication administration task requiring knowledge and skills within the licensed nurse's scope of practice. Assistive personnel (AP) are not authorized to perform this procedure due to the potential for complications and the need for clinical judgment.

Choice B rationale

Providing postmortem care is a task that AP can perform as it involves basic care activities, such as bathing and positioning, which do not require specialized nursing skills. This allows the nurse to focus on more complex patient needs.

Choice C rationale

Suctioning a tracheostomy is a procedure that requires clinical assessment and intervention skills. Due to the potential for complications, it is within the licensed nurse's scope of practice, not the AP's.

Choice D rationale

Changing a peripheral IV dressing involves assessment skills and requires sterile technique to prevent infection. This task is beyond the scope of practice for AP and should be performed by a licensed nurse.

Choice A rationale

Documenting the refusal in the client's medical record is important for legal and clinical reasons, ensuring there's a record of the client's decision and the nurse's response. However, it doesn't address the client's immediate concerns or needs.

Choice B rationale

Returning the medication to the medication cabinet is a necessary step to ensure medication safety and avoid accidental administration. Yet, it does not address the client's reasons for refusal or the potential risks involved.

Choice C rationale

The nurse’s first action should be to provide client education about the importance of taking the medication and the potential consequences of refusal (e.g., increased blood pressure, risk of stroke or heart attack). Addressing the client’s concerns about side effects can encourage adherence or lead to an alternative treatment plan.Client autonomy is respected, but ensuring informed refusal is part of the nurse’s role.

Choice D rationale

The provider should be informed, but only after the nurse has attempted to educate and address the client’s concerns. The provider may adjust the prescription if side effects are problematic.