A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?

Check the capillary refill every 4 hrs

Compare the pedal pulses every 4 hrs

Answer and Explanation

The Correct Answer is B

A. Check the capillary refill every 4 hrs Incorrect
The nurse should check capillary refill distally every 4 hr for a client whops elastic bandages on their lower extremities.

B. Compare the pedal pulses every 4 hrs CORRECT
The nurse should compare the pedal pulses bilaterally every week to check for adequate circulation for a client who has elastic bandages on their
lower extremities.

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Correct Answer is B

Explanation

A) Autonomy refers to the right of the client to make their own decisions about their care. In this scenario, the nurse respects the client's decision not to take the pill as it is, but does not stop there.
B) Beneficence is the principle of doing good and acting in the best interest of the client. By offering to break the pill, the nurse is actively seeking a solution to ensure the client receives the necessary medication, which is in the client's best interest.
C) Justice relates to fairness and the equal distribution of resources. While important, it is not the primary principle being demonstrated in this situation.
D) Nonmaleficence means to do no harm. Although breaking the pill could be seen as avoiding harm by preventing the client from choking, it is more about ensuring the client's treatment continues effectively, which aligns more closely with beneficence.

A. Show the assistive personnel where to apply the medication. B. Ask the client when the previous nurse last applied the medication. C. Identify the client by comparing the medication administration record with the client's room number. D. Compare the label of the medication container with the medication administration record three times.

Correct Answer is D

Explanation

A. Show the assistive personnel where to apply the medication: This action is not appropriate because only licensed healthcare providers, such as nurses, are allowed to administer
medications.
B. Ask the client when the previous nurse last applied the medication: While communication with the client is important, it is not a reliable method to verify medication administration accuracy.
C. Identify the client by comparing the medication administration record with the client's room number: This action is insufficient to verify the correct client because there could be multiple clients with the same medication due.
D. Compare the label of the medication container with the medication administration record three times: Correct. This action is known as the "three checks" and is an essential step in medication administration. The nurse should compare the medication label with the medication administration record before removing the medication, after removing the medication, and at the bedside before administering the medication.

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A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?

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