Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to administer medications to a client who states. "I don't want to take those drugs.’ Which of the following actions should the nurse take?
A. Explain the purpose for the medications.
The nurse should provide information about the purpose, benefits, and potential side effects of the medications to help the client make an informed decision. Educating the client may alleviate their concerns and encourage adherence to the treatment plan. This should come after asking them why they do not want to take the medication.
B. Tell the client the physician wants him to take the medications.
Simply stating that the physician wants the client to take the medications does not provide the client with adequate information or address their concerns, undermining their autonomy.
C. Ask the client why he is refusing to take the medication.
Asking why is an assessment - the very first step in the nursing process. It respects the patient’s autonomy, uncovers the reason for refusal (e.g., fear of side effects, misunderstanding, cost, cultural/religious beliefs, prior bad experience, or allergy), and lets you tailor your response (education, alternative meds, contacting the prescriber). If the patient lacks capacity or the refusal poses immediate danger, that changes the response - but you must assess first.
D. Document that the client refuses the medication.
This is correct as a secondary action after education and efforts to resolve the client's concerns. Documentation should include the client's reason for refusal, any teaching provided, and the healthcare provider's notification if needed.
E. None
None
F. None
None
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Pharmacology Proctored Exam 2. Take the full exam now
Similar Questions
A nurse is caring for a child who is allergic to penicillin. The nurse should verify which of the following prescriptions with the provider?
A. Erythromycin
None
B. Gentamicin
None
C. Amoxicillin-clavulanate
According to UpToDate, cross-reactivity between penicillins and other beta-lactam antibiotics such as cephalosporins can occur in some cases1. Amoxicillin is a type of penicillin, so the nurse should verify this prescription with the provider to ensure that it is safe for the client to take.
D. Amphotericin B
None
Full Explanation
According to UpToDate, cross-reactivity between penicillins and other beta-lactam antibiotics such as cephalosporins can occur in some cases. Amoxicillin is a type of penicillin, so the nurse should verify this prescription with the provider to ensure that it is safe for the client to take.
Which assessment Is most important for the nurse to obtain when a patient is being treated with a neuromuscular-blocking agent?
A. Respiratory assessment for patent airway.
Neuromuscular-blocking agents paralyze the muscles, including the respiratory muscles. Therefore, it is crucial to ensure that the patient maintains a patent airway and is able to breathe effectively. The nurse should monitor the patient's respiratory rate, depth, and effort, as well as assess for signs of airway obstruction, such as stridor or wheezing.
B. Skin assessment for rash
C. Blood pressure assessment for orthostatic hypotension
D. Assessment far fluid volume overload
Full Explanation
Neuromuscular-blocking agents paralyze the muscles, including the respiratory muscles. Therefore, it is crucial to ensure that the patient maintains a patent airway and is able to breathe effectively. The nurse should monitor the patient's respiratory rate, depth, and effort, as well as assess for signs of airway obstruction, such as stridor or wheezing.
Skin assessment for rash (option b), blood pressure assessment for orthostatic hypotension (option c), and assessment for fluid volume overload (option d) may also be important assessments for the nurse to obtain, but they are not the most critical assessments when a patient is being treated with a neuromuscular-blocking agent.
A nurse is preparing to administer cephalexin oral suspension to an older adult client who has difficulty swallowing pills. Which of the following actions should the nurse take?
A. Store the medication at room temperature
Cephalexin oral suspension should typically be stored in the refrigerator to maintain its stability and effectiveness. Storing it at room temperature could affect its potency.
B. Avoid shaking the medication before administration
Shaking the oral suspension is necessary to ensure the medication is evenly distributed before each dose, providing the client with the correct dosage of active ingredients. Failure to shake the suspension can result in uneven dosing.
C. Check the client for a penicillin allergy
Cephalexin is a cephalosporin antibiotic, and there is a potential for cross-sensitivity in clients who are allergic to penicillin. Up to 10% of people with a penicillin allergy may also be allergic to cephalosporins. Checking for a penicillin allergy helps prevent an adverse reaction, making it a critical safety measure before administering cephalexin.
D. Monitor the client for constipation
While some antibiotics can cause gastrointestinal side effects, constipation is not a common adverse effect associated with cephalexin. The nurse should instead monitor for other side effects like diarrhea, which is more typical with antibiotics and can indicate a mild side effect or a more severe condition, such as Clostridioides difficile infection.
Full Explanation
A. Cephalexin oral suspension should typically be stored in the refrigerator to maintain its stability and effectiveness. Storing it at room temperature could affect its potency.
B. Shaking the oral suspension is necessary to ensure the medication is evenly distributed before each dose, providing the client with the correct dosage of active ingredients. Failure to shake the suspension can result in uneven dosing.
C. Cephalexin is a cephalosporin antibiotic, and there is a potential for cross-sensitivity in clients who are allergic to penicillin. Up to 10% of people with a penicillin allergy may also be allergic to cephalosporins. Checking for a penicillin allergy helps prevent an adverse reaction, making it a critical safety measure before administering cephalexin.
D. While some antibiotics can cause gastrointestinal side effects, constipation is not a common adverse effect associated with cephalexin. The nurse should instead monitor for other side effects like diarrhea, which is more typical with antibiotics and can indicate a mild side effect or a more severe condition, such as Clostridioides difficile infection.