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 D
Explanation
Choice A rationale
Instilling ophthalmic medication directly on the cornea can cause irritation and discomfort. Medications should be administered in the conjunctival sac.
Choice B rationale
Asking the client to tightly squeeze their eyes shut after instillation can expel the medication, reducing its effectiveness. Gentle closing of the eyes is recommended.
Choice C rationale
Cleaning the eye from the outer canthus to the inner canthus is not the proper method. The correct method is to clean from the inner canthus to the outer canthus to avoid contaminating the inner eye.
Choice D rationale
Applying pressure to the nasolacrimal duct after instillation helps prevent the medication from draining into the nasolacrimal system, ensuring better absorption in the eye.
Correct Answer is C
Explanation
Choice C rationale
The large intestine absorbs water and electrolytes from the remaining indigestible food matter, forming and eliminating solid waste (stool). This absorption process is vital for
maintaining the body's fluid and electrolyte balance.
Choice A rationale
The large intestine does not produce vitamin D; this occurs in the skin when exposed to sunlight. The large intestine’s primary functions are absorption and waste formation.
Choice B rationale
Preventing the reflux of food into the esophagus is the function of the lower esophageal sphincter, not the large intestine. The large intestine deals with waste processing rather than regulating esophageal function.
Choice D rationale
The secretion of digestive enzymes is a function of the pancreas, stomach, and small intestine. The large intestine does not secrete enzymes but focuses on absorbing water and electrolytes.