A nurse is caring for a client who refuses a prescribed influenza immunization. Which of the following actions should the nurse take first?
Ask the client to describe their concerns.
Contact the provider who prescribed the immunization.
Provide the client with education about the immunization.
Document the client’s refusal of the immunization.
The Correct Answer is A
Choice A rationale
Asking the client to describe their concerns allows the nurse to understand the client’s perspective and address any misconceptions or fears they may have about the influenza immunization.
Choice B rationale
Contacting the provider is important but should be done after understanding the client’s concerns to provide a comprehensive report.
Choice C rationale
Providing education is essential but should follow understanding the client’s specific concerns to tailor the information effectively.
Choice D rationale
Documenting the refusal is necessary but should be done after addressing the client’s concerns and providing education.
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Correct Answer is C
Explanation
Choice A rationale
A standing prescription is an order that applies to all patients who meet certain criteria and is not specific to a single administration. It is used for routine treatments and does not apply to a one-time pre-transfusion medication.
Choice B rationale
A stat prescription is an urgent order that requires immediate administration, typically within minutes. It is used for emergency situations and does not apply to a pre-transfusion medication given one hour before the procedure.
Choice C rationale
A single prescription is a one-time order for a specific medication to be given at a specific time. In this case, diphenhydramine 50 mg by mouth once, one hour prior to transfusion, fits the definition of a single prescription.
Choice D rationale
A PRN (pro re nata) prescription is an order for medication to be given as needed based on the patient’s condition. It is not applicable to a scheduled pre-transfusion medication.
Correct Answer is C
Explanation
Choice A rationale
Monitoring calcium levels is not typically necessary for patients taking lisinopril, as it does not significantly affect calcium levels.
Choice B rationale
Sodium levels are not commonly affected by lisinopril, so routine monitoring is not required.
Choice C rationale
Lisinopril can cause hyperkalemia (high potassium levels), so monitoring potassium levels is crucial to prevent complications.
Choice D rationale
Magnesium levels are not significantly impacted by lisinopril, so routine monitoring is not necessary.