A nurse opens unit-dose of a prescribed medication prior to administering it to a client. After education, the client refuses to take the medication. Which of the following actions should the nurse take?

Notify the facility’s ethics committee

Return the opened medication in the medication cart

Report the incident to the provider

Fill out an incident report

Answer and Explanation

The Correct Answer is C

A) Notify the facility’s ethics committee:
While it may be relevant to involve an ethics committee in certain complex situations, such as when there are concerns about patient autonomy or ethical decision-making, the refusal of a medication by a client is generally a standard issue that does not immediately require ethics consultation.

B) Return the opened medication in the medication cart:
Returning an opened unit-dose medication to the cart is not appropriate. Once a unit-dose medication is opened, it cannot be reused due to safety concerns (e.g., contamination, dosage errors). The opened medication should be disposed of properly according to the facility's policies for medication handling and disposal.

C) Report the incident to the provider:
The provider should be notified when a client refuses medication, especially if the medication is essential for the client’s treatment or health condition. It is important for the nurse to document the refusal and inform the provider so that appropriate follow-up can be arranged, including possible reassessment of the treatment plan, alternative medications, or further education for the client.

D) Fill out an incident report:
An incident report is typically completed for situations that involve safety issues, errors, or accidents that may affect patient safety or quality of care. While refusal of medication is an important event, it does not generally require an incident report unless it involves an unusual or dangerous situation, such as a medication error or patient harm.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A) Clean the skin near the drain in a circular motion from the outside to the inside:
When cleaning around a drain, the nurse should use a circular motion, but it is important to clean from the inside (near the drain) outward to prevent introducing bacteria into the drain site. Cleaning from the outside to the inside increases the risk of contaminating the wound and could cause infection.

B) Empty the drainage device when it is half full:
For a Penrose drain, the drainage is typically absorbed by a dressing rather than being collected in a drainage device. In general, for drains like Jackson-Pratt or Hemovac, emptying the device when it is half full is correct, but this is not applicable to a Penrose drain. A Penrose drain relies on passive drainage, and there is no reservoir that requires emptying.

C) Place a perforated gauze pad around the drain to absorb drainage:
A Penrose drain is an open drain that allows drainage of fluids from a wound or surgical site. A perforated gauze pad should be placed around the drain to absorb the drainage and keep the surrounding area clean and dry. This helps prevent infection and maintains a sterile environment around the wound.

D) Connect the drain to continuous low-pressure suction:
A Penrose drain does not require suction. It is a passive drain, relying on gravity to facilitate the drainage of fluid. Suction is typically used for other types of drains, such as Jackson-Pratt or Hemovac drains, which require a suction mechanism to actively draw out fluid.

A. Holds their hands below than/bows while rinsing off soap B. Uses hot water to wash their hands C. Turns off the faucet with their hands D. Washes their hands for 10 seconds

Correct Answer is A

Explanation

A) Holds their hands below the elbows while rinsing off soap:
This is the correct practice when performing hand hygiene. To prevent contamination, hands should be kept below the elbows while rinsing to allow the water and soap to flow downward and away from the clean hands. This helps to avoid contaminating the hands with water running down the forearms.

B) Uses hot water to wash their hands:
The temperature of the water should be warm, not hot. Hot water can irritate the skin and cause dryness, which may lead to skin breaks, a potential route for pathogen entry. Therefore, warm water is recommended for hand hygiene, as it is effective and more comfortable for the skin.

C) Turns off the faucet with their hands:
The faucet should be turned off using a paper towel or another method that avoids re-contaminating the hands after washing. Using clean hands to turn off the faucet would defeat the purpose of hand hygiene, as the faucet handle is a common area for bacterial contamination.

D) Washes their hands for 10 seconds:
The proper duration for washing hands is at least 20 seconds, not 10. This ensures that enough time is taken to properly clean all surfaces of the hands, including the palms, backs of hands, between fingers, and under fingernails. Shortening this time can lead to inadequate cleansing, leaving pathogens on the hands.

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A nurse opens unit-dose of a prescribed medication prior to administering it to a client. After education, the client refuses to take the medication. Which of the following actions should the nurse take?

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Explanation

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Correct Answer is A

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