A nurse is assessing a client’s understanding of their medication regimen. The client nods in agreement but does not respond verbally. What is the nurse’s best action?
Assume the client understands and proceed with the regimen.
Repeat the instructions using different words.
Document that the client has full understanding of the regimen.
Ask the client to verbally respond to the Questions.
The Correct Answer is D
Choice A rationale
Assuming the client understands and proceeding with the regimen is incorrect. It does not verify the client’s understanding and could lead to non-compliance or errors in medication administration.
Choice B rationale
Repeating the instructions using different words may help, but it does not ensure that the client has understood the information. It is important to verify understanding through the client’s response.
Choice C rationale
Documenting that the client has full understanding of the regimen without verification is incorrect. It assumes understanding without confirmation, which could lead to potential errors.
Choice D rationale
Asking the client to verbally respond to the questions is the best action. It ensures that the client has understood the information and allows the nurse to clarify any misunderstandings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A 30-year-old male patient with an active GI bleed requiring multiple blood transfusions is not suitable for assignment to an LPN. This patient is unstable and requires close monitoring and frequent assessments, which are beyond the LPN’s scope of practice. The RN should manage this patient to ensure proper care and timely interventions.
Choice B rationale
A 55-year-old male patient who is post-surgery and ready for discharge, requiring discharge instructions, is also not suitable for assignment to an LPN. Discharge instructions involve comprehensive education and assessment of the patient’s understanding, which are responsibilities of the RN. The RN must ensure the patient comprehends the instructions and can safely manage their care at home.
Choice C rationale
A 40-year-old diabetic patient requiring re-teaching on insulin administration is the best choice for assignment to an LPN. This patient is stable and the task of re-teaching insulin administration falls within the LPN’s scope of practice. The LPN can effectively provide education and ensure the patient understands how to administer insulin correctly.
Choice D rationale
A newly admitted patient is not suitable for assignment to an LPN. New admissions require comprehensive assessments and care planning, which are responsibilities of the RN. The RN must evaluate the patient’s condition, develop a care plan, and initiate appropriate interventions.
Correct Answer is D
Explanation
Choice A rationale
Fatigue is a subjective symptom reported by the client. It is based on the client’s personal experience and cannot be objectively measured or observed by the nurse. Therefore, it is not considered objective data.
Choice B rationale
Dizziness is also a subjective symptom reported by the client. It reflects the client’s personal experience and cannot be directly observed or measured by the nurse. As such, it is not considered objective data.
Choice C rationale
Numbness is another subjective symptom reported by the client. It is based on the client’s personal sensation and cannot be objectively measured or observed by the nurse. Therefore, it is not considered objective data.
Choice D rationale
Physical examination results are objective data. They are obtained through direct observation, measurement, and assessment by the nurse. Examples of objective data include vital signs, physical examination findings, and laboratory results. These data are reproducible and can be verified by other healthcare professionals.
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