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 B
Explanation
Choice A rationale
An ileal conduit does not provide the client with control over elimination. It is a type of urinary diversion, and the client wears an external pouch to collect urine.
Choice B rationale
In an ileal conduit, the client's ureters are attached to a section of the small intestine, which is then brought to the surface of the abdomen to form a stoma. Urine flows through this conduit into an external pouch.
Choice C rationale
An ileal conduit is not a tube that directly connects the kidney to an external pouch. It involves using a section of the small intestine to create a passageway for urine to exit the body.
Choice D rationale
Stool is not passed through an ileal conduit. The ileal conduit is specifically for urinary diversion, while stool passes through the regular gastrointestinal tract.
Correct Answer is C
Explanation
Choice A rationale
The end of the stoma is typically not painful after the procedure. Pain at the stoma site could indicate complications such as infection or ischemia.
Choice B rationale
A healthy stoma should be pink or red in color. A purple color could indicate compromised blood flow or other complications that require medical attention.
Choice C rationale
The stoma is typically placed in the right lower abdomen to allow for easier management and care, as it is usually associated with the terminal ileum.
Choice D rationale
After an ileostomy, the stool is usually liquid to semi-formed, not solid, because the colon, which absorbs water to solidify stool, is bypassed.