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 B
Explanation
Choice A rationale
Asking the family member to provide identification does not ensure that the caller is authorized to receive patient information. Even with identification, the nurse cannot verify the caller’s relationship to the patient or their authorization to access confidential information.
Choice B rationale
Not providing any information over the phone is the correct action to protect patient confidentiality. Healthcare providers must ensure that patient information is only shared with authorized individuals, and phone calls do not provide a secure method for verifying the caller’s identity.
Choice C rationale
Providing only publicly available information is not appropriate, as it still involves sharing patient-related details without proper verification. Any disclosure of patient information, even if minimal, must be done with caution and proper authorization.
Choice D rationale
Informing the family member that they need to visit in person is a better approach, but it still does not guarantee that the individual is authorized to receive patient information. The nurse should follow established protocols for verifying authorization before sharing any details.
Correct Answer is D
Explanation
Choice A rationale
Planning involves setting goals and determining the appropriate interventions to achieve those goals. It is not the step being performed when changing a wound dressing.
Choice B rationale
Evaluation involves assessing the effectiveness of the interventions and determining if the goals have been met. It is not the step being performed when changing a wound dressing.
Choice C rationale
Assessment involves gathering data about the client’s condition. While assessment is an ongoing process, it is not the primary step being performed when changing a wound dressing.
Choice D rationale
Implementation involves carrying out the planned interventions. Changing a wound dressing is an example of implementing a nursing intervention.
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