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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Correct Answer is C

Explanation

A) Granulation tissue forming at the bottom of the wound bed:
Granulation tissue typically forms in wounds that heal by secondary intention. This type of healing occurs when the wound edges are not approximated (e.g., a large or open wound), and new tissue must form to fill the gap. In primary intention healing, the wound edges are well approximated, and granulation tissue is not the hallmark of the healing process, although some may appear early on.

B) Healing of the wound is prolonged:
Wounds healing by primary intention generally heal more quickly than those healing by secondary intention. In primary intention, the wound edges are approximated with sutures, staples, or adhesive, allowing for a faster and more efficient healing process. Therefore, prolonged healing is not expected with primary intention]

C) Skin edges of the wound are sutured closed:
This is the correct finding for a wound healing by primary intention. Primary intention healing occurs when the wound edges are brought together (approximated) and secured with sutures, staples, or adhesive strips. This method promotes faster healing and minimal scarring because the tissue is directly aligned.

D) Wound is contaminated at the time of injury:
Wounds that heal by primary intention are generally clean and not contaminated. If a wound is contaminated or infected at the time of injury, it is more likely to heal by secondary intention, where the tissue must fill in from the base upwards, which takes longer and may result in more scarring.

A. Role-play B. Question-and-answer C. Discussion D. Return demonstration

Correct Answer is D

Explanation

A) Role-play:
Role-playing is a teaching strategy where the client or learner acts out a scenario or situation to practice certain behaviors, such as interacting with others in a social or clinical setting. In this case, the nurse is not asking the client to simulate a scenario or interact with others, but instead, to physically perform a specific task (walking with a walker).

B) Question-and-answer:
The question-and-answer method involves the nurse asking the client questions to assess understanding or clarify information. This method typically involves verbal interaction rather than performing a physical skill. In this scenario, the nurse is not simply asking questions, but rather observing the client as they perform the physical task of walking with a walker.

C) Discussion:
Discussion is a method of teaching where ideas or concepts are shared and discussed, often in a conversational format. While the nurse might use discussion as part of the overall teaching, the act of having the client physically demonstrate walking with a walker is a separate and more focused teaching strategy.

D) Return demonstration:
Return demonstration is the teaching strategy in which the nurse shows the client how to perform a task (such as walking with a walker) and then asks the client to perform the task themselves to confirm understanding and skill acquisition. This method allows the nurse to assess the client’s ability to perform the task correctly and ensures that the client has learned the skill effectively.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a wound that is healing by primary intention. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is teaching a client how to walk using a walker. After showing the client the procedure, the nurse asks the client to perform the skill. Which of the following types of teaching strategies is the nurse utilizing

Correct Answer is D

Explanation

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