During morning medication administration, a competent adult client declines their prescribed antihypertensive drug. The client tells the practical nurse (PN), 'That pill makes me feel lightheaded, so I refuse to swallow it today.' Arrange the PN's actions in the correct chronological order to advocate for the client's rights and ensure safety. All options must be used.
- 1Withhold the antihypertensive medication to respect the client's right of refusal.
- 2Collect current vital signs to evaluate the client's complaint of feeling lightheaded.
- 3Reinforce teaching about the medication's purpose and the risks of missing a dose.
- 4Notify the prescribing healthcare provider of the refusal and the assessment data.
- 5Document the client's refusal, the objective findings, and the provider notification in the medical record.
Answer
The correct sequence of actions is to first withhold the medication, then collect vital signs, reinforce teaching, notify the healthcare provider, and finally document the event.
When a competent client refuses a prescribed treatment or medication, the practical nurse's immediate responsibility is to honor that right and withhold the dose to prevent any perception of coercion. Subsequently, because the client articulated a specific clinical symptom (feeling lightheaded), the nurse must prioritize data collection by obtaining vital signs to ensure the client is not experiencing an adverse event like severe hypotension. Once safety is verified, the nurse reinforces teaching so the client comprehends the medical risks associated with missing the dose. The nurse then communicates the client's decision and the assessment data to the healthcare provider for potential adjustments to the care plan. Finally, the nurse documents the entire chronological sequence in the health record to maintain legal compliance and continuity of care.
Step-by-Step Solution
Key Concept
Client Rights: Refusal of Treatment and Advocacy