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. Decreased peripheral pulses B. Heart rate 108/min C. Respiratory rate 10 breathes/min D. Dilated pupils

Correct Answer is B

Explanation

A) Decreased peripheral pulses:
Increased body temperature typically causes vasodilation rather than vasoconstriction, leading to improved blood flow rather than decreased. As a result, peripheral pulses are more likely to be normal or even increased in response to fever. Decreased peripheral pulses would be more indicative of conditions like shock or hypoperfusion, not fever.

B) Heart rate 108/min:
Fever causes an increase in metabolic demand, which often results in a compensatory increase in heart rate (tachycardia). This phenomenon, known as "fever tachycardia," occurs as the body attempts to circulate blood more rapidly to meet the increased oxygen and nutrient demands caused by elevated body temperature. A heart rate of 108 beats per minute is a normal response to fever, particularly when the temperature reaches 39°C (102.27°F).
C) Respiratory rate 10 breaths/min:
A respiratory rate of 10 breaths per minute is considered bradypnea (abnormally slow breathing), which is typically not associated with fever. Fever usually leads to an increase in respiratory rate (tachypnea) as the body attempts to cool itself through increased evaporation of sweat and breathing. A respiratory rate of 10 breaths/min is more likely to be seen in conditions like drug overdose, head injury, or respiratory depression, rather than fever.
D) Dilated pupils:
Dilated pupils (mydriasis) are typically associated with sympathetic nervous system activation, which can be caused by certain drugs, trauma, or neurological conditions. Fever, however, generally causes only mild changes in pupil size and is more likely to lead to constricted pupils (miosis) in response to certain stress hormones. Dilated pupils are not a typical finding with fever.

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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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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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