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.

Answer and Explanation

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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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.

A. Bowel pattern B. Oxygen saturation C. Respiratory assessment. D. Temperature E. Neurological status F. X-ray results G. Heart rate

Correct Answer is ["B","C","D","E","F"]

Explanation

B.Oxygen saturation (92% on room air): A drop in oxygen saturation from 96% to 92% indicates impaired gas exchange, which may require oxygen therapy or further evaluation for respiratory compromise.
C. Respiratory assessment (crackles, chest tightness, productive cough with blood): Crackles and productive cough with hemoptysis are concerning for possible tuberculosis (TB) or another serious respiratory infection. Immediate notification ensures timely isolation and further diagnostic testing.
D. Temperature (38.8°C/101.8°F): The elevated temperature indicates a possible infection or worsening inflammatory process, especially concerning given the night sweats and recent international travel history.
E. Neurological status (lethargy): The progression from an alert state to lethargy suggests potential worsening of the client’s condition, possibly due to hypoxia, infection, or sepsis. Early identification is critical for preventing deterioration.
F. X-ray results (calcification in upper lobes): Calcifications in the upper lung lobes are characteristic of previous or latent TB infection. This, combined with the client’s current symptoms, requires prompt reporting to initiate appropriate infection control measures.

Findings Not Reported:
A.Bowel pattern (normoactive, last BM this morning): The bowel pattern is normal and not immediately relevant to the acute respiratory concerns.
G. Heart rate (114/min): Though elevated, the heart rate is likely a secondary response to the fever and respiratory compromise. While important to monitor, it does not warrant immediate provider notification independently.

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A nurse is caring for a client who has refused medications. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has dysphagia and is pocketing food in their cheeks during meals. Which of the following interventions should the nurse recommend?

Correct Answer is B

Explanation

A nurse is assisting in the care of a client. Exhibits The nurse is assisting in the care of the client. Which of the following findings should the nurse report to the provider? Select the 5 findings the nurse should report.

Correct Answer is ["B","C","D","E","F"]

Explanation

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