After the nurse hands a client a medication, the client says, "What is this red tablet for? I have always taken a yellow pill." What is the most appropriate action for the nurse to take?
Withhold the drug and recheck the MAR with the health care provider’s order sheet.
Explain that the health care provider probably changed the drug today to something more effective and administer it.
Administer the medication, but make a mental note to check on it later.
Describe the action of the red tablet to the client and administer it.
The Correct Answer is A
Choice A reason: Withholding and rechecking ensures safety; a color change signals a potential error, and verifying the MAR against orders prevents administering the wrong drug.
Choice B reason: Assuming a change is risky; without confirmation, administering an unverified drug could harm the patient if it’s not the intended prescription.
Choice C reason: Administering then checking later endangers the patient; a wrong drug could cause adverse effects, and delayed verification violates safety protocols.
Choice D reason: Describing and giving without verification is unsafe; the red tablet may not match the order, risking incorrect treatment or allergic reactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Bed rest increases clot risk and deconditioning; vasodilators lower pressure, but mobility is beneficial unless contraindicated, making this overly restrictive.
Choice B reason: Assisting ambulation helps, but it’s less proactive; it doesn’t address orthostatic hypotension risks at initiation of movement, where falls are most likely.
Choice C reason: Monitoring intake/output tracks fluid status, not directly addressing vasodilation’s hypotensive effects during position changes, missing the primary safety concern.
Choice D reason: Rising slowly counters orthostatic hypotension from vasodilation; it allows autoregulation to stabilize pressure, reducing fall risk in an active elderly patient.
Correct Answer is C
Explanation
Choice A reason: Understanding jokes assumes comprehension but ignores cultural comfort; humor’s acceptability varies, and this misses emotional readiness assessment.
Choice B reason: Jokes about staff may offend or confuse; without patient input, this risks cultural insensitivity, especially in Asian contexts valuing respect for authority.
Choice C reason: Asking feelings respects cultural norms; humor’s therapeutic effect depends on patient receptivity, ensuring it aligns with individual and cultural preferences.
Choice D reason: Joking about conditions can distress; it’s culturally inappropriate in many Asian settings, potentially worsening trust or emotional state without consent.
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