A patient refuses medication. Which is the nurse’s first action?

Discreetly hide the medication in the patient’s favorite gelatin.

Agree with the patient’s decision and document it in the chart.

Explore with the patient reasons for not wanting to take the medication.

Educate the patient about the importance of the medication.

Answer and Explanation

The Correct Answer is C

A: Discreetly hiding the medication in the patient’s favorite gelatin is unethical and violates the patient’s right to informed consent. This approach undermines trust and can lead to further resistance or legal issues.

B: Agreeing with the patient’s decision and documenting it in the chart is important, but it should not be the first action. The nurse needs to understand the patient’s reasons for refusal before making any decisions or documentation.

C: Exploring with the patient the reasons for not wanting to take the medication is the appropriate first action. This approach allows the nurse to understand the patient’s concerns, address any misconceptions, and provide relevant information. It also respects the patient’s autonomy and promotes a collaborative approach to care.

D: Educating the patient about the importance of the medication is crucial, but it should follow the exploration of the patient’s reasons for refusal. Understanding the patient’s perspective first ensures that the education provided is relevant and addresses specific concerns.

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Correct Answer is C

Explanation

A: Checking the client’s skin every 8 hours is not frequent enough to prevent skin breakdown in a client with urinary incontinence. More frequent checks are necessary to identify and address any issues promptly.

B: Cleaning the client’s skin and perineum with hot water can cause skin irritation and dryness. It is better to use lukewarm water and gentle cleansers to maintain skin integrity.

C: Applying a moisture barrier ointment to the client’s skin is an effective way to prevent skin breakdown. The ointment creates a protective barrier that helps keep moisture away from the skin, reducing the risk of irritation and breakdown.

D: Requesting a prescription for the insertion of an indwelling urinary catheter is not the best first-line intervention for preventing skin breakdown. Catheters carry a risk of infection and should be used only when absolutely necessary.

A. “I will wear earphones during this test.” B. “A small probe is placed inside my ear.” C. “Small electrodes are placed on my scalp.” D. “A tuning fork is placed on my head.”

Correct Answer is D

Explanation

A: Wearing earphones is not part of the Rinne test. Earphones are used in other types of hearing tests, such as audiometry.

B: A small probe is not used in the Rinne test. Probes are used in other diagnostic procedures, such as tympanometry.

C: Small electrodes are not used in the Rinne test. Electrodes are used in tests like electroencephalography (EEG).

D: A tuning fork is placed on the mastoid bone behind the ear and then near the ear canal during the Rinne test. This test compares air conduction to bone conduction of sound.

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A patient refuses medication. Which is the nurse’s first action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Correct Answer is C

Explanation

A nurse is teaching a client about the Rinne test. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

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