A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, "I'm not going to take this medication because it makes me sick and dizzy." Which of the following actions should the nurse take first?
Document the refusal in the client's medical record.
Return the medication to the medication cabinet.
Inform the client of the potential consequences of their refusal.
Notify the provider of the client's refusal.
The Correct Answer is C
Choice A Reason:
While documenting the refusal is important for accurate record-keeping and to ensure communication among the healthcare team, addressing the client's immediate concerns and attempting to resolve the issue of medication refusal should take precedence before documenting.
Choice B Reason:
Returning the medication is a procedural step but is not the immediate action needed when a client refuses medication due to adverse effects. First, it's important to address the client's concerns and discuss the potential consequences of refusal.
When a client refuses medication due to experiencing adverse effects, the initial action for the nurse to take is:
Choice C Reason:
Inform the client of the potential consequences of their refusal is correct. It's essential to engage in a conversation with the client to understand their concerns and educate them about the potential consequences of not taking their antihypertensive medication. The nurse should discuss the risks associated with untreated high blood pressure to ensure the client is informed about the importance of the prescribed medication.
Choice D Reason:
Notifying the provider is important, but it is generally done after the nurse has attempted to address the client’s concerns and informed them of the consequences. The provider should be informed if the refusal persists or if the nurse believes the situation requires further medical intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
"Encourage your partner to eat three large meals each day." Is incorrect. At the end of life, a patient's appetite might decrease, and they may not tolerate large meals. Encouraging large meals can cause discomfort or be inappropriate for their condition.
Choice B Reason:
"We will use an electric blanket to keep your partner warm." Is incorrect. While maintaining comfort is important, the use of an electric blanket might not be suitable as the patient's circulation and ability to regulate body temperature might be compromised.
Choice C Reason:
"Opioids will be restricted if your partner develops respiratory distress." Is incorrect.
Opioids can be appropriate for managing symptoms like pain or dyspnea at the end of life. Restricting opioids solely due to the risk of respiratory distress might hinder adequate symptom management. The use of opioids should be based on individual patient needs and careful assessment by healthcare providers.
Choice D Reason:
"Assume your partner can hear you, even if they do not respond." Is correct. This statement encourages communication and acknowledges the possibility that the patient might still be able to perceive their surroundings, even if they are not responsive. It supports the importance of providing emotional support and communication during the end-of-life process.
Correct Answer is A
Explanation
Choice A Reason:
Chlorine bleach is correct. Chlorine bleach is an effective disinfectant against bloodborne pathogens. It's recommended for cleaning surfaces contaminated with blood spills because it can destroy various microorganisms, including bacteria and viruses. However, it's essential to follow proper dilution guidelines and safety precautions when using bleach.
Choice B Reason:
Chlorhexidine gluconate is incorrect. While chlorhexidine gluconate is an antiseptic commonly used for skin disinfection before medical procedures or as a surgical scrub, it's not typically used for cleaning blood spills on surfaces. Its primary application is for skin disinfection, not environmental surface cleaning.
Choice C Reason:
Hydrogen peroxide is incorrect. Hydrogen peroxide is a mild antiseptic that can disinfect wounds or clean certain surfaces. However, it might not be as effective as chlorine bleach in dealing with blood spills. It's generally used more for superficial wound cleaning rather than for disinfecting large contaminated surfaces.
Choice D Reason:
Isopropyl alcohol is incorrect. Isopropyl alcohol is a commonly used disinfectant for surfaces, but when it comes to blood spills, it might not be as effective as chlorine bleach. While it can kill some pathogens, its efficacy against certain bloodborne pathogens may be limited compared to bleach.
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