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.

Answer and Explanation

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 B reason: This is the correct answer because withholding the medication until the dosage can be confirmed is a prudent action that ensures patient safety and avoids medication errors. The nurse should compare the prescribed dosage with the client's previous dosage and consult with the healthcare provider or the pharmacist if there is any discrepancy or doubt.

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.

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Correct Answer is C

Explanation

Choice A reason: When the client has ankle edema is not the most important time for the nurse to assess DTRs, as this is a common finding in pregnancy and does not indicate a neurological or vascular problem. This is a distractor choice.

Choice B reason: Within the first trimester of pregnancy is not the most important time for the nurse to assess DTRs, as this is a routine assessment that can be done at any time during pregnancy and does not reflect any specific risk or complication. This is another distractor choice.

Choice C reason: If the client has an elevated blood pressure is the most important time for the nurse to assess DTRs, as this can indicate preeclampsia, a serious condition that can cause seizures, stroke, and organ damage. DTRs can help detect hyperreflexia, which is a sign of increased intracranial pressure and impending eclampsia. Therefore, this is the correct choice.

Choice D reason: During admission to labor and delivery is not the most important time for the nurse to assess DTRs, as this is a standard assessment that can be done at any stage of labor and does not signify any urgent or emergent situation. This is another distractor choice.

A. Keep the bed in the lowest position and initiate seizure and fall precautions. B. Place an indwelling urinary catheter and measure strict intake and output. C. Maintain elevated positioning of the dependent joints on affected side. D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

Correct Answer is D

Explanation

Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.

Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.

Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.

Choice D reason: This is the correct answer because starting two large bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is a critical action for the nurse to take. IV catheters are devices that allow access to the bloodstream for fluid or medication administration. Fibrinolytic therapy is a treatment that dissolves blood clots that may block blood flow to vital organs, such as the brain or heart. The client's symptoms suggest a possible stroke, which is a medical emergency that occurs when blood flow to a part of the brain is interrupted, causing brain tissue damage or death. The nurse should start two large bore IV catheters in case one fails or becomes occluded, and review inclusion criteria for IV fibrinolytic therapy, such as onset of symptoms, blood pressure, blood glucose, coagulation status, and history of bleeding or trauma, to determine if the client is eligible for this potentially life-saving treatment.

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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?

Nursing Test Bank

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