A nurse is preparing to administer medication to a client who has Crohn's disease. The client states, "I want to skip this dose of my medication. I am too tired to take it." Which of the following actions should the nurse take?
Leave the medication on the client's bedside table to take later.
Return in 1 hr to administer the medication.
Mix the medication in applesauce to administer to the client.
Inform the client of the consequences of refusing the medication.
The Correct Answer is D
Choice A rationale:
Leaving the medication on the client's bedside table is not appropriate because it doesn't address the client's concerns and may result in the client not taking the medication at all. This choice does not promote the client's well-being.
Choice B rationale:
Returning in 1 hour to administer the medication doesn't address the client's immediate concerns and also doesn't provide adequate information about the medication's importance. Delaying the medication administration without proper communication is not ideal.
Choice C rationale:
Mixing the medication in applesauce may be appropriate in some cases, but it doesn't address the client's reluctance to take the medication due to fatigue. Additionally, the client's Crohn's disease might require specific instructions for medication administration that should not be altered without consulting the healthcare provider.
Choice D rationale:
The correct answer. Informing the client of the consequences of refusing the medication is the most appropriate action. The nurse should engage in a therapeutic conversation with the client, explaining the importance of the medication in managing Crohn's disease symptoms and preventing complications. This choice respects the client's autonomy while providing necessary information for an informed decision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The answer isb. "Check the urinary output at 11:00 for John Doe and report it to me immediately.”
a. "Take vital signs every 2 hours for the client who had a cholecystectomy in room 6122.” is wrong because it does not specify which client to monitor.The AP should know the client’s name and room number for identification and safety purposes.
c. "Report to me if the chest tube drainage is excessive for Jane Doe in room 2438.” is wrong because it does not define what constitutes excessive drainage.The nurse should provide clear and measurable criteria for the AP to follow.
d. "Please notify me of any clients whose vital signs or blood glucose levels are significant.” is wrong because it is vague and does not indicate which clients to check, how often to check them, or what values are significant.The nurse should provide specific and individualized instructions for each client
Correct Answer is B
Explanation
The correct answer is b. Inform the assistive personnel of the client’s weight-bearing status.
Choice A: Assess the client’s incision every 8 hours for the first 48 hours. While it is important to monitor the incision site for signs of infection, the frequency of every 8 hours for the first 48 hours may not be necessary unless specified by the surgeon or the patient’s condition warrants it.
Choice B: Inform the assistive personnel of the client’s weight-bearing status. This is the correct answer. After a total hip arthroplasty, it’s crucial to communicate the client’s weight-bearing status to all members of the healthcare team, including assistive personnel. This helps ensure that everyone is aware of the client’s mobility limitations and can assist the client safely.
Choice C: Instruct the client to cross their legs at the ankles when sitting in a chair. This is not recommended. After a hip arthroplasty, patients are typically advised not to cross their legs to prevent dislocation of the new hip joint.
Choice D: Teach the client’s partner to assist the client to flex the hip at least 120° each hour. This is not recommended. After a hip arthroplasty, patients are typically advised to avoid flexing the hip more than 90 degrees to prevent dislocation of the new hip joint1. Therefore, flexing the hip at least 120° each hour could potentially harm the patient.
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