A nurse opens unit-dose of a prescribed medication prior to administering it to a client. After education, the client refuses to take the medication. Which of the following actions should the nurse take?

Notify the facility’s ethics committee

Return the opened medication in the medication cart

Report the incident to the provider

Fill out an incident report

Answer and Explanation

The Correct Answer is C

A) Notify the facility’s ethics committee:
While it may be relevant to involve an ethics committee in certain complex situations, such as when there are concerns about patient autonomy or ethical decision-making, the refusal of a medication by a client is generally a standard issue that does not immediately require ethics consultation.

B) Return the opened medication in the medication cart:
Returning an opened unit-dose medication to the cart is not appropriate. Once a unit-dose medication is opened, it cannot be reused due to safety concerns (e.g., contamination, dosage errors). The opened medication should be disposed of properly according to the facility's policies for medication handling and disposal.

C) Report the incident to the provider:
The provider should be notified when a client refuses medication, especially if the medication is essential for the client’s treatment or health condition. It is important for the nurse to document the refusal and inform the provider so that appropriate follow-up can be arranged, including possible reassessment of the treatment plan, alternative medications, or further education for the client.

D) Fill out an incident report:
An incident report is typically completed for situations that involve safety issues, errors, or accidents that may affect patient safety or quality of care. While refusal of medication is an important event, it does not generally require an incident report unless it involves an unusual or dangerous situation, such as a medication error or patient harm.

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Correct Answer is A

Explanation

A) Dehydration:
Diarrhea, especially when prolonged for several days, leads to significant fluid and electrolyte loss, which can result in dehydration. Common signs of dehydration include dry mucous membranes, decreased skin turgor, low urine output, hypotension, and increased heart rate. Dehydration is one of the most expected findings in a patient with prolonged diarrhea due to the loss of water and electrolytes from the body.
B) Rigid abdomen:
A rigid abdomen could indicate peritonitis or a serious abdominal condition such as bowel perforation, which is a medical emergency. This would not be expected in a patient with uncomplicated diarrhea. Rigid abdominal muscles are typically associated with acute abdominal emergencies rather than simple diarrhea.
C) Hypothermia:
Hypothermia is generally not associated with diarrhea. Diarrhea is more likely to cause fever or a normal body temperature due to the body's inflammatory response to infection or irritation. Hypothermia typically occurs in cases of prolonged exposure to cold or in critically ill patients, but it is not a typical response to diarrhea alone.
D) Decreased bowel sounds:
While decreased or absent bowel sounds can be seen in bowel obstruction or paralytic ileus, it is not typically a finding associated with diarrhea. In fact, in the early stages of diarrhea, increased bowel sounds (hyperactive bowel sounds) are often noted due to the rapid peristalsis and gastrointestinal irritation.

A. Assessment B. Planning C. Evaluation D. Analysis

Correct Answer is B

Explanation

A) Assessment:
Assessment involves gathering and analyzing data about the client’s health status and needs. While gathering information from the social worker and physical therapist may be part of the assessment process, the actual collaborative work in preparing the discharge plan is more aligned with the planning phase of the nursing process.

B) Planning:
Planning is the correct answer because it involves formulating goals, interventions, and expected outcomes for the client’s care, including discharge projections. In this case, the nurse, social worker, and physical therapist are working together to develop a comprehensive discharge plan tailored to the client’s needs, which is a key part of the planning phase.

C) Evaluation:
Evaluation occurs after interventions are implemented to assess whether the goals have been met and the outcomes achieved. Since the nurse is still in the process of preparing the discharge plan, evaluation has not yet occurred.

D) Analysis:
Analysis is the process of interpreting assessment data to identify problems or needs. While analysis is part of the assessment phase, it does not describe the collaborative action of creating a discharge plan, which is clearly a planning task.

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A nurse opens unit-dose of a prescribed medication prior to administering it to a client. After education, the client refuses to take the medication. Which of the following actions should the nurse take?

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