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

Answer and Explanation

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.

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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.

A. A documented nursing assessment every hour B. Constant one-on-one supervision during the first hour and then video monitoring C. A face-to-face evaluation by the psychiatrist within one hour of restraint D. Review of the appropriateness of restraints every hour

Correct Answer is C

Explanation

Choice A reason: Hourly nursing assessments are important for monitoring safety in restraints but are not the primary legal requirement. Assessments ensure no physical harm, but psychiatric evaluation within one hour is mandated to confirm restraint necessity, making this option secondary in priority for immediate post-restraint protocol.

Choice B reason: Constant supervision may be used, but transitioning to video monitoring after one hour does not meet strict regulatory standards for restraints. Face-to-face psychiatric evaluation within one hour is required to assess ongoing need and ensure patient rights, making this option less accurate for legal compliance.

Choice C reason: Regulatory standards (e.g., CMS, Joint Commission) mandate a face-to-face evaluation by a psychiatrist within one hour of initiating restraints to assess necessity, safety, and alternatives. This ensures compliance with mental health laws, protects patient rights, and prevents overuse, making it the required action.

Choice D reason: Reviewing restraint appropriateness hourly is part of ongoing care but is not the primary requirement. A psychiatrist’s face-to-face evaluation within one hour takes precedence to ensure legal and ethical use, as it confirms the clinical justification for restraints, making this option secondary.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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