Nursing Jurisprudence and Ethics for Texas Nurses Practice Exam

What must a nurse document after a patient refuses medication?

1. The number of medications on hand

2. The reason for the refusal and the patient's understanding

3. Only the patient's name and date of refusal

4. Other patients' reactions to the medication

The correct answer is: The reason for the refusal and the patient's understanding

Documenting the reason for a patient's refusal of medication and their understanding of the situation is crucial in nursing practice. This documentation serves multiple purposes: it ensures that there is a clear record of the patient’s decision-making process, supports the patient's autonomy, and reflects that the nurse has provided appropriate information about the medication and its potential effects. When a patient refuses medication, it is essential to capture not only that the refusal occurred but also the rationale behind it. This could include any concerns the patient may have about the medication, misconceptions they might hold, or any side effects they wish to avoid. By also documenting the patient's understanding, the nurse demonstrates that a clear communication process took place, which is vital for legal and ethical considerations. This documentation supports the nurse’s adherence to informed consent principles, where a patient must have a complete understanding of their treatment options. In contrast, documenting the number of medications on hand, only the patient's name and date of refusal, or other patients' reactions to the medication does not directly address the specifics of the refusal situation. These other options fail to provide a comprehensive view of the patient’s choice and may not uphold the standards of care and patient safety that are fundamental to nursing practice.