A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, 'The doctor didn't tell me I was supposed to receive an enema.' Which of the following nursing actions is appropriate at this time?

Correct Answer: A

Rationale: Correct Answer: A. Check the client's medical record for the provider's prescription. Rationale: 1. Verifying the provider's prescription is essential to ensure the client's safety and adherence to medical orders. 2. It is crucial to confirm the medical necessity before proceeding with the procedure. 3. Checking the medical record respects the client's right to informed consent and promotes patient-centered care. Summary: - Option B does not address the importance of verifying the provider's prescription. - Option C assumes the client's comfort with the procedure without confirming the doctor's order. - Option D prematurely escalates the situation without confirming the medical necessity.

Correct Answer: C

Rationale: The correct answer is C: Explain the risk the client faces if she leaves the facility. Rationale: 1. Warfarin is a blood thinner that requires close monitoring of the INR to prevent complications like bleeding. 2. An INR of 3.5 is above the therapeutic range, putting the client at risk for bleeding. 3. It is crucial for the nurse to educate the client about the potential consequences of leaving against medical advice. 4. By explaining the risks, the nurse can help the client make an informed decision about their health. 5. This action demonstrates the nurse's duty to ensure the client's safety and well-being. Summary of other choices: A: Forcing the client to sign an AMA form does not address the client's concerns or provide necessary education about the risks. B: Threatening the client with insurance consequences is coercive and does not prioritize the client's health. D: Involving security is not appropriate in this situation and does not address the client

Correct Answer: B

Rationale: The correct answer is B because reducing the incidence of foot amputations is a specific and measurable goal in managing diabetes. This goal directly addresses a serious complication of diabetes and reflects the program's effectiveness in improving outcomes. Choices A, C, and D do not focus on measurable outcomes related to diabetes management, making them less relevant goals for the program. Providing proper foot care (choice A) is important but does not guarantee improved outcomes. Reserving a facility (choice C) and distributing materials (choice D) are logistical details rather than program goals.

Correct Answer: D

Rationale: The correct answer is D because the nurse should first communicate with the AP to understand the reasons for refusal. By asking about concerns, the nurse can address any issues and provide clarification or support. This approach promotes open communication, teamwork, and problem-solving. Taking the specimen to the lab (A) may not address underlying concerns. Reporting to the charge nurse (B) or completing an incident report (C) should be done after understanding the AP's perspective to prevent unnecessary escalation.

Correct Answer: C

Rationale: Rationale for Correct Answer (C): - Encouraging clients to receive annual flu immunization helps prevent flu-related illnesses, reducing healthcare costs associated with hospitalizations and treatments. - Annual flu immunization is a cost-effective preventive measure that can help avoid costly complications and reduce healthcare expenses in the long run. Summary of Incorrect Choices: - Choice A: Waiting to empty a colostomy bag until it is three-fourths full can lead to skin irritation and infection, increasing costs for treating complications. - Choice B: Delegating closed irrigation to assistive personnel can compromise quality of care and potentially lead to complications, increasing costs. - Choice D: Using sterile technique for ostomy care in clients with tracheostomy is irrelevant and does not contribute to cost reduction in client care.