Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed, and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse take in response to this situation?

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HESI Fundamentals Quizlet Questions

Question 1 of 5

Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed, and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse take in response to this situation?

Correct Answer: C

Rationale: In this scenario, the nurse acted appropriately by withholding the medication, consulting with the healthcare provider, and administering the newly prescribed dose, albeit with a delay. The correct course of action for the nurse is to document all these events in the nurse's notes. Documenting the sequence of actions taken is crucial for maintaining an accurate record of the client's care, ensuring transparency, and providing essential information for future reference and continuity of care.

Question 2 of 5

When assisting a client with right-sided hemiplegia to get into a wheelchair, how should the nurse position the wheelchair?

Correct Answer: A

Rationale: Positioning the wheelchair on the left side of the bed facing the foot of the bed is the correct approach when assisting a client with right-sided hemiplegia. Placing the wheelchair on the left side allows the client to stand on their unaffected foot and pivot to sit down safely. This positioning facilitates a smoother transfer and helps maintain the client's stability during the process.

Question 3 of 5

While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 5

During a urethral catheterization on a female, where would the healthcare provider observe the urethral meatus after separating the labia?

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 5 of 5

What is the main purpose of the working phase of the nurse-patient relationship?

Correct Answer: B

Rationale: The main purpose of the working phase in the nurse-patient relationship is to implement nursing interventions that are specifically tailored to achieve the expected patient outcomes. During this phase, the nurse actively works with the patient to put the care plan into action and make progress towards reaching the desired health goals. It involves the application of therapeutic communication, problem-solving, and interventions to address the patient's needs. Establishing rapport and trust is typically done in the orientation phase, while defining roles and boundaries usually occurs in the introductory phase of the relationship.

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