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
Clients should be instructed to hold their breath for about 10 seconds after inhalation, not 2 seconds. This allows the medication to reach deeper into the lungs.
Choice B rationale
The MDI canister should not be washed after each use. Instead, it should be cleaned regularly to ensure proper functioning and avoid medication buildup.
Choice C rationale
Clients should be instructed to inhale the medication slowly and deeply over a few seconds, rather than quickly for 1 second. This ensures proper delivery of the medication to the lungs.
Choice D rationale
Shaking the MDI prior to administration is essential. This action mixes the medication evenly, ensuring that the correct dose is delivered with each puff.
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.