When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. Which action should the nurse take?
Explain to the client that the dosage has been changed.
Withhold the medication until the dosage can be confirmed.
Inform him that he may refuse the medication and document whether or not he takes it.
Tell him to take the medication then verify the dosage at the next healthcare team meeting.
The Correct Answer is B
Choice A reason: Explaining to the client that the dosage has been changed is not a safe action because it may not be true. The nurse should not assume that the prescribed dosage is correct or different from the previous one without verifying it with the healthcare provider or the medication record.
Choice C reason: Informing him that he may refuse the medication and documenting whether or not he takes it is not a responsible action because it does not address the issue of dosage discrepancy. The nurse should respect the client's right to refuse medication, but should also educate him about the benefits and risks of taking or not taking it. The nurse should also try to resolve any barriers or concerns that may affect the client's adherence to medication.
Choice D reason: Telling him to take the medication then verifying the dosage at the next healthcare team meeting is not a timely action because it may cause harm or complications to the client. The nurse should not administer any medication without checking its accuracy and appropriateness for the client. The nurse should also report and document any medication incidents as soon as possible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice B is correct because monitoring abdominal girth is an important intervention for a client with cirrhosis of the liver and end stage liver disease. Cirrhosis of the liver can cause portal hypertension, which is an increased pressure in the portal vein that carries blood from the digestive organs to the liver. Portal hypertension can lead to ascites, which is an accumulation of fluid in the abdominal cavity. The nurse should measure and record the abdominal girth daily and report any significant changes.
Choice C is correct because reporting serum albumin and globulin levels is an important intervention for a client with cirrhosis of the liver and end stage liver disease. Cirrhosis of the liver can impair the synthesis of proteins, such as albumin and globulin, which are essential for maintaining fluid balance, immune function, and blood clotting. The nurse should monitor and report the serum albumin and globulin levels and administer supplements or transfusions as prescribed.
Choice D is correct because noting signs of bleeding and edema is an important intervention for a client with cirrhosis of the liver and end stage liver disease. Cirrhosis of the liver can cause coagulopathy, which is a disorder of blood clotting, due to reduced production of clotting factors and increased consumption of platelets. Coagulopathy can lead to bleeding from various sites, such as the gums, nose, esophagus, stomach, or rectum. The nurse should observe and report any signs of bleeding and apply pressure or bandages as needed. Cirrhosis of the liver can also cause hypoalbuminemia, which is a low level of albumin in the blood, due to decreased synthesis or increased loss of albumin. Hypoalbuminemia can lead to edema, which is swelling caused by fluid retention in the tissues. The nurse should assess and report any signs of edema and elevate the affected limbs or apply compression stockings as indicated.
Choice E is correct because limiting fluid intake to 1500 mL daily is an important intervention for a client with cirrhosis of the liver and end stage liver disease. Fluid restriction can help prevent or reduce ascites and edema by decreasing the fluid load on the circulatory system and the kidneys. The nurse should measure and record the fluid intake and output and educate the client on how to limit their fluid intake.
Choice A is incorrect because providing a diet low in phosphorus is not a specific intervention for a client with cirrhosis of the liver and end stage liver disease. A diet low in phosphorus may be indicated for clients with chronic kidney disease or hyperphosphatemia, but not for clients with cirrhosis of the liver. The nurse should provide a diet that is high in calories, carbohydrates, and protein, but low in sodium, fat, and alcohol for clients with cirrhosis of the liver.
Correct Answer is B
Explanation
Choice B is correct because assessing the DTRs of a pregnant client with an elevated blood pressure can help detect signs of preeclampsia, a serious complication of pregnancy that can cause seizures, organ damage, and fetal death. Preeclampsia can cause hyperreflexia, which is an exaggerated response of the DTRs.
Choice A is incorrect because ankle edema is not a reliable indicator of preeclampsia and does not require assessing the DTRs. Ankle edema is a common finding in normal pregnancy due to increased blood volume and fluid retention.
Choice C is incorrect because assessing the DTRs during admission to labor and delivery is not as important as assessing them if the client has an elevated blood pressure. Assessing the DTRs during admission to labor and delivery can help monitor the client's neurological status, but it is not a priority action.
Choice D is incorrect because assessing the DTRs within the first trimester of pregnancy is not as important as assessing them if the client has an elevated blood pressure. Assessing the DTRs within the first trimester of pregnancy can help establish a baseline, but it is not a priority action.
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