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. Asking the client about the presence of pain. This is part of the assessment phase, as it involves gathering data.
B. Reinforcing teaching about the client's diagnosis. Teaching is part of the implementation phase, where planned interventions are carried out.
C. Establishing the priorities of client care. This is part of the planning phase, where care priorities are determined.
D. Comparing the client's current laboratory values to previous results. This is part of the evaluation phase, where the nurse assesses progress toward goals.

A. Client 1 B. Client 5 C. Client 2 D. Client 3 E. Client 4

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

Explanation

A. Client 1: Worsening of the pressure injury with purulent drainage indicates infection and failure of pressure injury prevention strategies.
B. Client 5: The stage 3 pressure injury reduced in size and severity to stage 2, with the absence of purulent drainage, indicating wound healing and effective intervention.
C. Client 2: WBC count decreased from 11,500/mm³ to within the normal range at 9,500/mm³, indicating improvement in pneumonia.
D. Client 3: Temperature reduced from 38.9°C to 38°C, with stabilization of vital signs, suggesting improvement in the wound infection.
E. Client 4: An increase in WBCs in the urine from 2 to 6 per low-power field suggests worsening of the urinary tract infection, indicating program ineffectiveness.

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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 assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

Correct Answer is B

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A nurse is reviewing the electronic medical records of clients following the implementation of a quality improvement plan to reduce health care associated infections. Exhibits Select the three clients whose findings indicate the program is effective.

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

Explanation

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