A nurse is caring for a client who has refused medications. Which of the following actions should the nurse take? (Select all that apply.)
Document the client's statement in the medical record.
Reinforce teaching about the purposes of the medications.
Tell the client they can take their medications later in the day.
Record non administration in the client's medication administration record.
Inform the pharmacy the client's medications will be wasted.
Correct Answer : A,B,D
A. Document the client's statement in the medical record. Accurate documentation is essential to provide a complete record of the client's care and decisions.
B. Reinforce teaching about the purposes of the medications. Providing information can help the client make informed decisions and reconsider their refusal.
C. Tell the client they can take their medications later in the day. This may not be appropriate, depending on the medication schedule and therapeutic requirements.
D. Record non-administration in the client's medication administration record (MAR). This ensures an accurate medication history and alerts other providers to the missed dose.
E. Inform the pharmacy the client's medications will be wasted. Medications are not automatically wasted upon refusal; they can often be returned or rescheduled.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A newborn has respiratory distress and requires oxygen: This is a clinical event requiring immediate intervention but not necessarily an error or unexpected event warranting an incident report.
B. A newborn has an Apgar score of 7 at 5 minutes after birth: An Apgar score of 7 is within a normal range and does not constitute an unusual or reportable incident.
C. A newborn receives erythromycin ophthalmic ointment 4 hours after birth: Erythromycin should be administered within 1 to 2 hours after birth to prevent neonatal eye infections. Delayed administration requires incident reporting.
D. A newborn receives a heel stick on the outer aspect of the heel: This is standard practice to prevent nerve and tissue damage during blood sampling and does not require an incident report.
Correct Answer is B
Explanation
A. Elevate the head of the client's bed to 45° during meals: The head should be elevated to 90° to reduce the risk of aspiration during meals.
B. Request a speech therapist consult from the provider: Speech therapists can assess swallowing difficulties and recommend appropriate strategies.
C. Instruct the client to tilt their head back when swallowing: This position increases the risk of aspiration by opening the airway during swallowing.
D. Administer liquids to the client using a syringe: Syringe administration can lead to choking or aspiration and is not a standard feeding practice for dysphagia clients.
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