An alert, competent client refuses to take her antihypertensive medication. The nurse has explained why the medication is important and the client states that she understands but doesn't want to take the medication. What is the best nursing action?

Give the medication anyway because it's important for the client

Withhold the medication and report it to the prescriber

Withhold the medication and file an incident report

Inform the client that the medication must be taken until the nurse gets an order to discontinue it

Answer and Explanation

The Correct Answer is B

Choice A rationale: Administering the medication against the client's will is not respectful of the client's autonomy and right to make decisions about her own care.

Choice B rationale: Withholding the medication and reporting it to the prescriber is appropriate. The prescriber can reassess the situation and determine the next course of action.

Choice C rationale: Withholding the medication and filing an incident report may be premature; it is essential to involve the prescriber first.

Choice D rationale: Informing the client that the medication must be taken until the nurse gets an order to discontinue it may not be the best approach, as it does not respect the client's right to refuse treatment. The prescriber should be involved in the decision-making process.

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Correct Answer is D

Explanation

Choice A rationale: Suctioning is not typically performed as part of routine pulmonary nursing care every eight hours. It is indicated based on the client's clinical need.

Choice B rationale: Suctioning frequency should be determined by the client's condition and physician's orders, not a fixed hourly schedule.

Choice C rationale: Routine coughing and swallowing of sputum do not necessarily warrant suctioning. Suctioning is indicated when the client is unable to manage secretions effectively.

Choice D rationale: Suctioning is appropriate when the client has gurgling respirations and is unable to cough effectively, indicating the need to clear the airway.

A. inject air into the regular insulin, then into the NPH. B. inject air into both vials and withdraw the regular insulin first. C. Inject air into and withdraw the NPH immediately. D. withdraw the regular insulin first.

Correct Answer is B

Explanation

Choice A rationale: Injecting air into the regular insulin and then into the NPH is not the correct sequence.

Choice B rationale: Injecting air into both vials and withdrawing the regular insulin first is the correct sequence when drawing up a combination of short-acting and intermediate- acting insulins.

Choice C rationale: Injecting air into and withdrawing the NPH immediately is not the correct sequence.

Choice D rationale: Withdrawing the regular insulin first is not the correct sequence when preparing a mixed insulin injection.

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An alert, competent client refuses to take her antihypertensive medication. The nurse has explained why the medication is important and the client states that she understands but doesn't want to take the medication. What is the best nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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