A nurse in a rehabilitation facility is administering medications to a client who was admitted earlier that day. The client refuses two of the medications, stating, "I've never taken these before." Which of the following actions should the nurse take first?

Consult the pharmacist about the client's prescribed medications.

Call the provider to clarify the client's prescribed medications.

Compare the client's medication administration record with the prescriptions on the transfer orders.

Review the intended purpose of the prescribed medications with the client.

Answer and Explanation

The Correct Answer is C

A.   Consult the pharmacist about the client's prescribed medications: While consulting the pharmacist may provide valuable information about the medications, it may not be the first action to take in this scenario.
B.   Call the provider to clarify the client's prescribed medications: While it may be necessary to clarify the client's medications with the provider, it may not be the first action to take, especially if there are discrepancies in the documentation.
C.   Compare the client's medication administration record with the prescriptions on the transfer orders: This is the correct answer. Comparing the client's medication administration record with the prescriptions on the transfer orders can help identify any discrepancies or errors in medication administration, ensuring patient safety and adherence to prescribed therapy.
D.   Review the intended purpose of the prescribed medications with the client: While reviewing the intended purpose of the medications with the client is important for informed decision-making, it may not be the first action to take if there are concerns about the accuracy or appropriateness of the prescribed medications.

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Correct Answer is A

Explanation

A. Elevating the head of the client’s bed to 30° before inserting a nasogastric (NG) tube is incorrect. The proper position for NG tube insertion is typically with the client sitting upright at 45–90° to reduce the risk of aspiration and facilitate the passage of the tube through the esophagus. This action requires intervention by the charge nurse to correct the positioning.

B. Maintaining the chest tube collection device below the level of the insertion site when ambulating the client is correct. This positioning prevents backflow of drainage into the pleural space, which could lead to complications such as pneumothorax or infection. No intervention is needed for this action.

C. Assisting the client into a fetal position on their side in preparation for a lumbar puncture is correct. This position helps to widen the spaces between the vertebrae, allowing easier access to the spinal canal for the procedure. This action does not require intervention.

D. Assessing the client’s gag reflex following an esophagogastroduodenoscopy (EGD) is correct. After an EGD, the client’s gag reflex must return before allowing oral intake to prevent aspiration. This action does not require intervention.

A. Make arrangements to take over the client's care. B. Recommend that both nurses be terminated. C. Escort the nurses to the nurses' lounge to continue the discussion. D. Contact the house supervisor to mediate the conflict.

Correct Answer is C

Explanation

A: This action does not address the issue of the nurses' unwillingness to care for the patient and fails to resolve the conflict or the underlying concerns about infection control and staff safety.

B: Termination is a drastic measure that may not be justified without a thorough investigation and should be considered only after other conflict resolution strategies have failed.

C: Moving the discussion to a private area is appropriate to maintain professionalism and confidentiality, allows for a calm environment to discuss the matter thoroughly, and prevents further disruption of the workplace.

D: Involving the house supervisor is a step that could be taken if the charge nurse is unable to resolve the conflict, but it is not the first action that should be taken as the charge nurse has the authority to manage staff issues directly

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A nurse in a rehabilitation facility is administering medications to a client who was admitted earlier that day. The client refuses two of the medications, stating, "I've never taken these before." Which of the following actions should the nurse take first?

Nursing Test Bank

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Correct Answer is C

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