A patient refuses medication. Which is the nurse’s first action?

Discreetly hide the medication in the patient’s favorite gelatin.

Agree with the patient’s decision and document it in the chart.

Explore with the patient reasons for not wanting to take the medication.

Educate the patient about the importance of the medication.

Answer and Explanation

The Correct Answer is C

A: Discreetly hiding the medication in the patient’s favorite gelatin is unethical and violates the patient’s right to informed consent. This approach undermines trust and can lead to further resistance or legal issues.

B: Agreeing with the patient’s decision and documenting it in the chart is important, but it should not be the first action. The nurse needs to understand the patient’s reasons for refusal before making any decisions or documentation.

C: Exploring with the patient the reasons for not wanting to take the medication is the appropriate first action. This approach allows the nurse to understand the patient’s concerns, address any misconceptions, and provide relevant information. It also respects the patient’s autonomy and promotes a collaborative approach to care.

D: Educating the patient about the importance of the medication is crucial, but it should follow the exploration of the patient’s reasons for refusal. Understanding the patient’s perspective first ensures that the education provided is relevant and addresses specific concerns.

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Correct Answer is C

Explanation

A: Requesting the risk manager to obtain consent for HIV testing from the client is important but should not be the first action. Immediate steps to reduce the risk of infection are more urgent.

B: Completing an incident report is necessary for documentation and follow-up but is not the immediate priority following a needle stick injury.

C: Washing the site of injury with soap and water is the first and most immediate action. This helps to reduce the risk of infection by removing any potential contaminants from the wound.

D: Consenting to post-exposure treatment with antiretroviral medications is important if there is a risk of HIV exposure. However, this should follow the initial step of cleaning the wound.

A. Reposition the client at least every 2 hours. B. Clean the wound with hydrogen peroxide solution. C. Massage reddened areas with dressing changes. D. Apply a heat lamp twice a day.

Correct Answer is A

Explanation

A: Repositioning the client at least every 2 hours is crucial for preventing further pressure ulcers and promoting healing. Regular repositioning helps to relieve pressure on vulnerable areas, improve circulation, and prevent skin breakdown.

B: Cleaning the wound with hydrogen peroxide solution is not recommended. Hydrogen peroxide can damage healthy tissue and delay wound healing. Saline or a gentle wound cleanser should be used instead.

C: Massaging reddened areas with dressing changes is not advisable. Massaging can cause further damage to already compromised skin and tissues. Gentle handling and avoiding pressure on these areas are more appropriate.

D: Applying a heat lamp twice a day is not a standard intervention for pressure ulcers. Heat lamps can cause burns and further damage to the skin. Maintaining a moist wound environment and using appropriate dressings are better practices.

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A patient refuses medication. Which is the nurse’s first action?

Nursing Test Bank

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