38. A nurse encounters a client who refuses to take a prescribed medication. What is the appropriate action of the nurse?

38. A nurse encounters a client who refuses to take a prescribed
medication. What is the appropriate action of the nurse?
by

1 Answer

Answer :

C. Explore the possible reason why the client refuses
the prescribed medication
by

Related questions

63. A hypertensive client is taking herbal supplement for his hypertension. He was prescribed antihypertensive medication. The client wants to continue taking his herbal medication to lower his blood pressure. The nurse’s most appropriate action is to

Description : 63. A hypertensive client is taking herbal supplement for his hypertension. He was prescribed antihypertensive medication. The client wants to continue taking his herbal medication to lower his blood pressure. The nurse’s most appropriate action is to

Last Answer : B. Tell the client that herbal supplements have no proven therapeutic effects

When the intern-in-charge did the skin prep and catheterized the client, the circulating nurse noticed when the intern withdrew the catheter from the vagina. What is your appropriate and immediate action? A. Stop the intern and do the catheterization yourself B. Offer to change the catheter C. Alcoholize the tip of the catheter before reinserting the catheter

Description : When the intern-in-charge did the skin prep and catheterized the client, the circulating nurse noticed when the intern withdrew the catheter from the vagina. What is your appropriate and ... . Offer to change the catheter C. Alcoholize the tip of the catheter before reinserting the catheter

Last Answer : B. Offer to change the catheter

72. The client is to have surgery in 10 days. Lugol’s solution 4 gtts po was prescribed in 10 days. The client asked the nurse for the purpose of the drug. Which response of the nurse is correct?

Description : 72. The client is to have surgery in 10 days. Lugol’s solution 4 gtts po was prescribed in 10 days. The client asked the nurse for the purpose of the drug. Which response of the nurse is correct?

Last Answer : A. It decreases the risk of bleeding

57. The client was prescribed Ocreotide acetate (Sandostatin). Nurse Carla would monitor for which of the following side effects?

Description : 57. The client was prescribed Ocreotide acetate (Sandostatin). Nurse Carla would monitor for which of the following side effects?

Last Answer : A. Abdominal pain

40. The nurse should ensure that all components of medications are documented. Identify all these components. 1. Dosage, route and frequency 2. Name of client and medication 3. Date and time the medication was ordered 4. Dosage, route, frequency and strength 5. Physician’s signature and specialty 6. Physician’s signature and PRC license number

Description : 40. The nurse should ensure that all components of medications are documented. Identify all these components. 1. Dosage, route and frequency 2. Name of client and medication 3. Date and time ... and strength 5. Physician's signature and specialty 6. Physician's signature and PRC license number

Last Answer : C. All except 5 and 6

87. When the staff nurse on duty encounters a problem that cannot be solved using nursing knowledge, skills and available resources, it is best for the nurse to consult the

Description : 87. When the staff nurse on duty encounters a problem that cannot be solved using nursing knowledge, skills and available resources, it is best for the nurse to consult the

Last Answer : C. Head nurse

n assisting the client to do deep breathing, coughing and turning to the sides on the first post-operative day, which nursing action would be most helpful for the client? A. Restate the importance of respiratory exercises B. Give the client reassurance that can he can cough, breathe deeply and turn to sides safely C. Administer the prescribed analgesic round the clock as prescribed D. Apply abdominal splint (pillow) while coughing

Description : n assisting the client to do deep breathing, coughing and turning to the sides on the first post-operative day, which nursing action would be most helpful for the client? A. Restate ... the prescribed analgesic round the clock as prescribed D. Apply abdominal splint (pillow) while coughing

Last Answer : D. Apply abdominal splint (pillow) while coughing

55. The nurse wants to know if the client is aware of the side effects of NSAID. What would be the most appropriate question of the nurse?

Description : 55. The nurse wants to know if the client is aware of the side effects of NSAID. What would be the most appropriate question of the nurse?

Last Answer : B. “Have you ever vomited blood or noticed very black stools?”

As the nurse monitors the client, she notices a bright red spot on the dressings which measures 4cm in diameter. The nurse should initially do which appropriate nursing intervention? A. Change the top dressing B. Continue to monitor the vital signs C. Notify the clients surgeon of a potential hemorrhage D. Assess the presence of a drain

Description : As the nurse monitors the client, she notices a bright red spot on the dressings which measures 4cm in diameter. The nurse should initially do which appropriate nursing intervention? A. Change the ... C. Notify the clients surgeon of a potential hemorrhage D. Assess the presence of a drain

Last Answer : D. Assess the presence of a drain

77. Nurse Kristine is to inject Demerol 75 mg to a post-TURP (transurethral resection of the prostate) client who is in pain. When she checked the narcotic cabinet, she found out a vial that is almost empty. She was able to aspirate 60 mg only. Nurse Kristine decided to inject it instead of making the client wait until the next Demerol vial is available. The action of the nurse violates which of the following ethical principles?

Description : 77. Nurse Kristine is to inject Demerol 75 mg to a post-TURP (transurethral resection of the prostate) client who is in pain. When she checked the narcotic cabinet, she found out a ... next Demerol vial is available. The action of the nurse violates which of the following ethical principles?

Last Answer : A. Justice

Which of the following guidelines is appropriate to helping family members cope with sudden death? a) Show acceptance of the body by touching it, giving the family permission to touch. The nurse should encourage the family to view and touch the body if they wish, since this action helps the family to integrate the loss.

Description : Which of the following guidelines is appropriate to helping family members cope with sudden death? a) Show acceptance of the body by touching it, giving the family permission to touch. The nurse ... avoid volunteering unnecessary information (e.g., patient was drinking at the time of the accident).

Last Answer : a) Show acceptance of the body by touching it, giving the family permission to touch. The nurse should encourage the family to view and touch the body if they wish, since this action helps the family to integrate the loss.

85. When the surgeon asked for suture to close the abdomen, sponge count has not been completed. Which of the following is the appropriate action of the scrub nurse?

Description : 85. When the surgeon asked for suture to close the abdomen, sponge count has not been completed. Which of the following is the appropriate action of the scrub nurse?

Last Answer : D. Informs the surgeon that sponge count has not been completed

A staff nurse was found charting blood glucose result without actually doing the procedure. What is the appropriate initial action of the senior nurse? A. Write and submit an explanation and reprimand as necessary B. Go on leave without pay C. Write an incident report D. Explain to the patient

Description : A staff nurse was found charting blood glucose result without actually doing the procedure. What is the appropriate initial action of the senior nurse? A. Write and submit an explanation and reprimand as necessary B. Go on leave without pay C. Write an incident report D. Explain to the patient

Last Answer : A. Write and submit an explanation and reprimand as necessary

The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log every injection of Demerol B. Make fraction dosage like 0.5 ml as 1 ml C. Demerol inventory must be checked every endorsement by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Description : The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log ... by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Last Answer : D. Review endorsement of clients who received Demerol within the last 24 hours

Nurse Mercy is setting up for an emergency caesarian section. The linen packs were damp although these were just taken from the sterilizer. The nurse’s appropriate action is A. Bring the linen packs back to the Central Supply section for quality control B. Change the damp linen pack C. Open the linen pack and allow to dry D. Do not use the damp linen

Description : Nurse Mercy is setting up for an emergency caesarian section. The linen packs were damp although these were just taken from the sterilizer. The nurse's appropriate action is A. Bring the linen packs back to the ... linen pack C. Open the linen pack and allow to dry D. Do not use the damp linen

Last Answer : D. Do not use the damp linen

Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient’s fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed. b) Minimal urine output of 50 milliliters per hour Minimal urine output may be less than 50 mL/hr. c) Minimal urine output of 10 milliliters per hour Minimal urine output must exceed 10 mL/hr. d) Minimal intake of 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Description : Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient's fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are ... 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Last Answer : a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed.

54. Albert is prescribed NSAID every four hours to relieve, fever, inflammation, and pericardial pain. To maximize the effect of the drug, the nurse would administer it

Description : 54. Albert is prescribed NSAID every four hours to relieve, fever, inflammation, and pericardial pain. To maximize the effect of the drug, the nurse would administer it

Last Answer : C. Round the clock on a consistent basis

When the nurse observes the patient’s urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Description : When the nurse observes the patient's urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake ... white urine may indicate infection, pyruria, or in the female patient, the use of vaginal creams.

Last Answer : a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Description : For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated ... make an opening in the capsule and squeeze out contents for administration by feeding tube.

Last Answer : a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

71. Before the nurse administers the medication, which of the following is most relevant for the nurse to ask?

Description : 71. Before the nurse administers the medication, which of the following is most relevant for the nurse to ask?

Last Answer : C. “When was your last menstruation?”

43. Mr. Gomez, 71 years old, has a history of chronic back pain. He thinks that his family perceives him as a “weakling” because he often asks for pain medication. Which of the following is the most therapeutic response of the nurse?

Description : 43. Mr. Gomez, 71 years old, has a history of chronic back pain. He thinks that his family perceives him as a “weakling” because he often asks for pain medication. Which of the following is the most therapeutic response of the nurse?

Last Answer : A. “It seems that you are worried. Which matter to you more? What people will say or getting relief from your pain?”

33. The client is scheduled to undergo appendectomy. Preparation for appendectomy includes the following: 1. Intravenous infusion 2. Laxative 3. Pubic area shaving 4. Enema 5. Shower 6. Pain medication

Description : 33. The client is scheduled to undergo appendectomy. Preparation for appendectomy includes the following: 1. Intravenous infusion 2. Laxative 3. Pubic area shaving 4. Enema 5. Shower 6. Pain medication

Last Answer : B. 1, 3, and 5

Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? a) Record the observation. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

Description : Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest ... finding to the physician immediately. Subcutaneous emphysema results from air entering the tissue planes.

Last Answer : a) Record the observation. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

When the female client reports a frothy yellow-brown vaginal discharge, the nurse suspects the client has a vaginal infection caused by a) trichomonas vaginalis. Trichomonas vaginalis causes a frothy yellow-white or yellow-brown vaginal discharge.

Description : When the female client reports a frothy yellow-brown vaginal discharge, the nurse suspects the client has a vaginal infection caused by a) trichomonas vaginalis. Trichomonas vaginalis causes a ... the external vulva and vaginal walls. d) chlamydia. Chlamydia causes a profuse purulent discharge.

Last Answer : a) trichomonas vaginalis. Trichomonas vaginalis causes a frothy yellow-white or yellow-brown vaginal discharge.

99. The companion asks why the client was advised to avoid iron supplements or vitamins. The correct response of the nurse would be

Description : 99. The companion asks why the client was advised to avoid iron supplements or vitamins. The correct response of the nurse would be

Last Answer : A. “These supplements enhance the production of RBC.”

88. When the nurse ensures that the client has plan for continuous care after leaving the health care facility and assists from the transition from one environment to another, she is doing a

Description : 88. When the nurse ensures that the client has plan for continuous care after leaving the health care facility and assists from the transition from one environment to another, she is doing a

Last Answer : A. Discharge plan

79. A scrub nurse is assisting an emergency Cesarian section on a 39-year-old laundry woman. Before closing the peritoneum, the surgeon asks, “How old is the client?” Holding the fallopian tube, the surgeon asks for a hemostat. The scrub nurse sensing that the surgeon is about to ligate the tube said, “Doctor there is no signed consent for tubal ligation.” The nurse just demonstrated which of the following?

Description : 79. A scrub nurse is assisting an emergency Cesarian section on a 39-year-old laundry woman. Before closing the peritoneum, the surgeon asks, How old is the client? Holding the fallopian ... there is no signed consent for tubal ligation. The nurse just demonstrated which of the following?

Last Answer : C. Advocacy

76. A client is being positioned for radical vulvectomy and a couple of clinical clerks wanted to come in to watch the surgery. The circulating nurse advise them to enter the OR suite later. Foremost, this decision of the nurse is directed towards

Description : 76. A client is being positioned for radical vulvectomy and a couple of clinical clerks wanted to come in to watch the surgery. The circulating nurse advise them to enter the OR suite later. Foremost, this decision of the nurse is directed towards

Last Answer : D. Preserving privacy

69. When Marina checked the capillary blood glucose of the client at 6 PM before meals as instructed by the senior nurse, the result showed 65 mg/dl. Which of the following will Marina do first?

Description : 69. When Marina checked the capillary blood glucose of the client at 6 PM before meals as instructed by the senior nurse, the result showed 65 mg/dl. Which of the following will Marina do first?

Last Answer : C. Check the physician’s order in case CBG is below 70 mg/dl

64. The client was placed on a low sodium diet. The wife asks the nurse which foods to include in the client’s diet while at home. The nurse should instruct to include which of these?

Description : 64. The client was placed on a low sodium diet. The wife asks the nurse which foods to include in the client’s diet while at home. The nurse should instruct to include which of these?

Last Answer : C. Fruits and vegetables

62. A 30-year-old client had cholesterol blood test before admission to the hospital. The nurse in charge would teach the family and significant others that the client should exercise to help keep the total cholesterol to a desired level of

Description : 62. A 30-year-old client had cholesterol blood test before admission to the hospital. The nurse in charge would teach the family and significant others that the client should exercise to help keep the total cholesterol to a desired level of

Last Answer : A. 140 mg/dl

61. A client with gout asks the nurse what food must be avoided so that the family can provide support. Which food has the highest in purine content and must be excluded from the dietary plan?

Description : 61. A client with gout asks the nurse what food must be avoided so that the family can provide support. Which food has the highest in purine content and must be excluded from the dietary plan?

Last Answer : D. Liver

51. Albert came to the hospital with chest pain and fever. After a thorough assessment by the doctor, he was admitted for pericarditis management. The nurse positions the client to reduce pain and discomfort. Describe this position.

Description : 51. Albert came to the hospital with chest pain and fever. After a thorough assessment by the doctor, he was admitted for pericarditis management. The nurse positions the client to reduce pain and discomfort. Describe this position.

Last Answer : C. Sit the client upright and lean forward

42. The nurse is to inject Vitamin B intramuscularly to another elderly client. Before injecting, the nurse explained that the client may feel some discomfort. This is an example of

Description : 42. The nurse is to inject Vitamin B intramuscularly to another elderly client. Before injecting, the nurse explained that the client may feel some discomfort. This is an example of

Last Answer : C. Anticipatory response

41. For a client complaining of mild musculoskeletal pain, the nurse will anticipate that the treatment for this client’s level of discomfort will include which of the following?

Description : 41. For a client complaining of mild musculoskeletal pain, the nurse will anticipate that the treatment for this client’s level of discomfort will include which of the following?

Last Answer : B. Acetaminophen

Reviewing the laboratory findings of the client, the nurse would found which findings are elevated? 1. White blood cell count 2. Total serum bilirubin 3. Alkaline phosphate 4. Red blood cell count 5. Cholesterol 6. Serum amylase A. 1, 2, and 3 B. 2, 3, and 4 C. 3, 5, and 6 D. 1, 2, and 6

Description : Reviewing the laboratory findings of the client, the nurse would found which findings are elevated? 1. White blood cell count 2. Total serum bilirubin 3. Alkaline phosphate 4. Red blood cell count 5. Cholesterol 6. Serum amylase A. 1, 2, and 3 B. 2, 3, and 4 C. 3, 5, and 6 D. 1, 2, and 6

Last Answer : A. 1, 2, and 3

To confirm the diagnosis of cholecystitis, the attending physician ordered a procedure that can detect gallstones as small as 1 – 2 cm and inflammation. The nurse would prepare the client for which specific diagnostic procedure? A. Cholangiography B. Ultrasonography C. Gall bladder series D. Oral cholecystogram

Description : To confirm the diagnosis of cholecystitis, the attending physician ordered a procedure that can detect gallstones as small as 1 - 2 cm and inflammation. The nurse would prepare ... specific diagnostic procedure? A. Cholangiography B. Ultrasonography C. Gall bladder series D. Oral cholecystogram

Last Answer : B. Ultrasonography

The Code of Ethics states that the nurse’s primary commitment is to the client whether an individual of family, group or community. Which nursing activity would best demonstrate the ethical principle called justice? A. The nurse providing care on a “first come – first served” basis B. Referring the client for evaluation to the social worker on duty regarding her socio-economic status C. The client’s preference is least considered D. The nurse’s providing care to maximize health according to available resources

Description : The Code of Ethics states that the nurse's primary commitment is to the client whether an individual of family, group or community. Which nursing activity would best demonstrate the ethical ... is least considered D. The nurse's providing care to maximize health according to available resources

Last Answer : A. The nurse providing care on a “first come – first served” basis

The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Description : The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Last Answer : A. Gastric decompression

The nurse instructs the nursing attendant to perform cleansing enema until the return flow is clear. The nursing attendant understood the instruction when she says, “I will A. Call you when the return flow is clear” B. Stop the enema only if the return flow is without formed fecal material” C. Need 1 liter of tap water to have clear return flow” D. Put the client in left Sim’s position to achieve the desired return flow.”

Description : The nurse instructs the nursing attendant to perform cleansing enema until the return flow is clear. The nursing attendant understood the instruction when she says, I will A. Call you when the return flow is ... flow D. Put the client in left Sim's position to achieve the desired return flow.

Last Answer : A. Call you when the return flow is clear”

In the immediate post-operative period, the nurse assesses coarse, high-pitched sound on inspiration by listening over the trachea with a stethoscope. The nurse should immediately A. Position client to Fowler’s B. Reassure the client that he is doing fine C. Suction the tracheostomy tube D. Report to the surgeon

Description : In the immediate post-operative period, the nurse assesses coarse, high-pitched sound on inspiration by listening over the trachea with a stethoscope. The nurse should immediately A. Position client to ... the client that he is doing fine C. Suction the tracheostomy tube D. Report to the surgeon

Last Answer : Which of the following expected outcomes for the patient is most relevant for the nursing diagnosis “At risk for imbalanced nutrition related to impaired swallowing”? A. Appropriate body weight maintained B. Fear of choking relieved C. Oral intake increased D. Swallowing of soft foods facilitated

Pre-operatively, the nurse identified the nursing dagnosis, “Knowledge Deficit: Post-operative communication strategies”. Which of the following is a relevant nursing intervention? A. Clarify information on purpose, anticipate benefits and consequences of total laryngectomy B. Explain that total laryngectomy results in loss of ability to verbally communicate C. Arrange a visit to a post-laryngectomy client who effectively uses an alternative form of verbal communication D. Illustrate means of communicating post- operatively

Description : Pre-operatively, the nurse identified the nursing dagnosis, Knowledge Deficit: Post-operative communication strategies . Which of the following is a relevant nursing intervention? A. ... uses an alternative form of verbal communication D. Illustrate means of communicating post- operatively

Last Answer : D. Illustrate means of communicating post- operatively

44. Mang Pedring has chronic pain due to osteoarthritis and has impaired speech. Which of the following is the most appropriate to determine his medication needs for pain?

Description : 44. Mang Pedring has chronic pain due to osteoarthritis and has impaired speech. Which of the following is the most appropriate to determine his medication needs for pain?

Last Answer : B. Asking the client to rate his pain on a scale of 0 to 10 by writing on a magic slate

100. The client complained of generalized pruritus. The following are appropriate nursing interventions except

Description : 100. The client complained of generalized pruritus. The following are appropriate nursing interventions except

Last Answer : B. Regulate the temperature to 25 degrees centigrade or lower

98. Phlebotomy was ordered as part of the therapy. You instructed the client and emphasized that the procedure can be repeated. The client inquired, “What is the primary aim of the procedure?” Your appropriate response is

Description : 98. Phlebotomy was ordered as part of the therapy. You instructed the client and emphasized that the procedure can be repeated. The client inquired, “What is the primary aim of the procedure?” Your appropriate response is

Last Answer : D. “It keeps the hematocrit within normal range.”

73. When the client returns to the unit after surgery, which technique is most appropriate to monitor bleeding from the incision?

Description : 73. When the client returns to the unit after surgery, which technique is most appropriate to monitor bleeding from the incision?

Last Answer : B. Assess for dampness at the back of the client’s neck

The nurse recommends which of the following types of therapeutic baths for its antipruritic action? a) Colloidal (Aveeno, oatmeal) Aveeno or oatmeal baths are recommended to decrease itching associated with a dermatologic disorder.

Description : The nurse recommends which of the following types of therapeutic baths for its antipruritic action? a) Colloidal (Aveeno, oatmeal) Aveeno or oatmeal baths are recommended to decrease itching ... Saline Saline baths have the same effects as saline dressings, not known to counteract itching.

Last Answer : a) Colloidal (Aveeno, oatmeal) Aveeno or oatmeal baths are recommended to decrease itching associated with a dermatologic disorder.

When the nurse prepares to give a bolus tube feeding to the patient and determines that the residual gastric content is 150 cc, her best action is to a) reassess the residual gastric content in 1 hour. If the gastric residual exceeds 100 cc 2 hours in a row, the physician should be notified.

Description : When the nurse prepares to give a bolus tube feeding to the patient and determines that the residual gastric content is 150 cc, her best action is to a) reassess the residual gastric content in ... residual exceeds 100 cc, the tube feeding should be withheld at that time, but not indefinitely.

Last Answer : a) reassess the residual gastric content in 1 hour. If the gastric residual exceeds 100 cc 2 hours in a row, the physician should be notified.