A nurse opens a unit-dose of a prescribed medication prior to administering it to a client.
The client refuses to take the medication. Which of the following actions should the nurse take?
Return the opened medication to the medication cart.
Report the incident to the provider.
Fill out an incident report.
Notify the facility's ethics committee.
Notify the facility's ethics committee.
The Correct Answer is C
Choice A rationale
Returning the opened medication to the medication cart is inappropriate because once a medication is opened and refused by a client, it must be disposed of properly. This action helps maintain safety and prevents contamination.
Choice B rationale
Reporting the incident to the provider is not necessary in this context as the refusal to take medication can be managed by the nurse by following the facility's protocol.
Choice C rationale
Filling out an incident report is required because the client's refusal to take the medication is considered a significant event. Incident reports are used to document and analyze such events to improve patient care and safety.
Choice D rationale
Notifying the facility's ethics committee is unnecessary for a medication refusal incident, as it does not involve an ethical dilemma requiring their intervention.
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Correct Answer is C
Explanation
Choice A rationale
Including toilet paper with the collected urine can contaminate the sample and affect the accuracy of the test results.
Choice B rationale
The first void at the start of the collection period should be discarded to ensure that only urine produced during the 24-hour period is collected.
Choice C rationale
Refrigerating the urine during the collection period helps preserve the sample and prevent bacterial growth, which could alter the test results.
Choice D rationale
The last void at the end of the collection period should be included to ensure that the full 24-hour period is accounted for in the collection.
Correct Answer is C
Explanation
Choice A rationale
Replacing the external urinary catheter once each day is unnecessary. The catheter should be changed based on clinical judgment and manufacturer's guidelines to maintain hygiene.
Choice B rationale
Inserting the catheter into the client's urethra is incorrect for an external urinary catheter. External catheters are designed to be placed outside the body.
Choice C rationale
Applying a barrier cream to the client's perineal skin is correct. Barrier creams protect the skin from moisture and prevent skin breakdown and irritation caused by urine.
Choice D rationale
Connecting the catheter to continuous wall suction is not appropriate. External urinary catheters should be connected to a drainage bag for proper urine collection. .