A nurse is assigned to administer oral medications to a client. Which action will the nurse do first if a client refuses to take prescribed oral medications?
Inform the client that the nurse will get reprimanded for not administering the medication
Document the client’s refusal on the medication administration record
Ask the client the reason for refusing the medication
Inform the client that refusal is not permitted and it is required that the client take the medication
The Correct Answer is C
Choice A reason: Informing the client about potential nurse reprimands is coercive and inappropriate, as it prioritizes the nurse’s interests over patient autonomy. This approach fails to explore the client’s reasons for refusal, which may involve side effects or mistrust, and does not support therapeutic communication or ethical care.
Choice B reason: Documenting refusal is necessary but not the first action. Exploring the reason for refusal allows the nurse to address concerns, potentially resolving issues like misunderstanding or side effects. Documentation follows after attempts to understand and educate, ensuring a therapeutic approach before recording the refusal.
Choice C reason: Asking the reason for refusal respects autonomy and initiates therapeutic communication. It identifies barriers like side effect fears or lack of understanding, enabling education or alternative solutions. This approach aligns with patient-centered care, addressing underlying issues to promote adherence while respecting the client’s rights.
Choice D reason: Stating that refusal is not permitted is coercive and violates autonomy. Clients have the right to refuse medication unless under involuntary treatment orders. This approach damages trust, escalates resistance, and contradicts ethical principles, making it an inappropriate initial response to medication refusal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Hypocalcemia may occur in AKI due to impaired vitamin D activation, but it is not a primary concern in the diuresis phase, where kidneys produce large urine volumes. Calcium imbalances are less immediate than fluid losses, which can rapidly destabilize hemodynamics during this phase.
Choice B reason: In the diuresis phase of AKI, kidneys regain function, producing excessive urine, which can lead to hypovolemia. Fluid loss depletes intravascular volume, causing hypotension, tachycardia, and organ hypoperfusion. Monitoring is critical to prevent dehydration and ensure adequate fluid replacement to maintain hemodynamic stability during recovery.
Choice C reason: Increased blood pressure is more common in the oliguric phase of AKI due to fluid overload. In the diuresis phase, excessive urine output reduces volume, potentially lowering blood pressure. Hypertension is not a typical complication during this phase, making it an incorrect focus for monitoring.
Choice D reason: Hyperkalemia is a concern in the oliguric phase of AKI due to reduced potassium excretion. In the diuresis phase, increased urine output facilitates potassium clearance, reducing hyperkalemia risk. Hypovolemia from excessive fluid loss is a more immediate concern during this phase of AKI recovery.
Correct Answer is B
Explanation
Choice A reason: White crystals (uremic frost) and yellowish skin in CKD indicate severe uremia due to toxin accumulation from impaired kidney function. Applying medicated lotion addresses skin symptoms but does not treat the underlying uremia, which can lead to life-threatening complications like metabolic acidosis, hyperkalemia, or encephalopathy. This action is secondary to addressing systemic toxicity through dialysis.
Choice B reason: Elevated BUN, creatinine, and uremic frost signify advanced CKD with uremia, requiring urgent dialysis to remove toxins and excess fluids. Notifying the provider ensures timely intervention to prevent complications such as seizures, coma, or cardiac arrhythmias due to electrolyte imbalances and toxin buildup, making this the priority action for patient safety.
Choice C reason: A cardiac monitor detects arrhythmias, which may occur in CKD due to hyperkalemia or fluid overload. However, monitoring alone does not address the root cause of uremia. Without dialysis to correct metabolic imbalances, arrhythmias may persist or worsen, making this action less urgent than initiating dialysis to stabilize the patient’s condition.
Choice D reason: Assessing a fistula for bruit and thrill ensures vascular access patency for dialysis. While important, it is not the priority when uremic symptoms are present, as dialysis orders must be secured first to address the acute uremic state and prevent life-threatening complications like encephalopathy or cardiac arrest due to toxin accumulation.
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