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. SOAP documentation B. Focus charting (DAR) C. Charting by exception (CBE) D. Problem-oriented medical record (POMR)

Correct Answer is C

Explanation

A) SOAP documentation:
SOAP (Subjective, Objective, Assessment, Plan) documentation is a method used for organizing and documenting client information. It focuses on both subjective and objective data, as well as the assessment and plan. While SOAP helps structure the documentation of patient conditions and interventions, it does not specifically focus on documenting only unexpected findings. It is a more comprehensive approach that includes normal and abnormal findings, not just the unexpected ones.

B) Focus charting (DAR):
Focus charting (DAR) is based on a client-centered approach and uses the components of Data, Action, and Response. It is a way of documenting observations and interventions, particularly in relation to specific patient problems or conditions. Focus charting is more about the care provided, responses to interventions, and client outcomes. While it may include unexpected findings, it doesn’t limit documentation exclusively to abnormal or unexpected events.

C) Charting by exception (CBE):
Charting by exception (CBE) is a documentation method that focuses on recording only the significant deviations from the norm. It emphasizes noting any abnormal or unexpected findings, and everything that is normal is assumed to be within expected limits and not documented. This method reduces the amount of documentation by excluding routine information and only highlighting significant, unexpected findings. Therefore, CBE is the correct answer in this scenario, as it involves documenting only unexpected or abnormal findings related to the client's condition.

D) Problem-oriented medical record (POMR):
POMR is a method of documentation that organizes client care around specific problems or diagnoses. It includes the identification of problems, interventions, and outcomes. While POMR focuses on client problems and plans of care, it does not specifically focus on documenting only unexpected findings. It may include both normal and abnormal findings related to each identified problem.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has had diarrhea for several days. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is documenting client care including only unexpected findings related to the client's condition. Which of the following documentation methods the nurse utilizing?

Correct Answer is C

Explanation

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