A 38-year-old client who is a Jehovah's Witness is involved in a major motor vehicle accident. The client was brought to the emergency department and was found to have lost too much blood, thus requiring a blood transfusion. The client is able to respond to questions appropriately. Which action should the nurse take in this situation?

Only fresh frozen plasma should be transfused to the client.

An immediate blood transfusion should be started due to the client's condition.

The client should be asked to decide about the blood transfusion.

The client's family should be notified immediately of the situation.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Fresh frozen plasma (FFP) is a component of blood used to replace clotting factors and is typically indicated for specific medical conditions like bleeding disorders or massive transfusions. In this case, the client requires red blood cells due to significant blood loss, so FFP alone is not the appropriate choice.

Choice B rationale:

Initiating an immediate blood transfusion without the client's consent is not ethically appropriate, especially considering the client's religious beliefs as a Jehovah's Witness. Respecting the client's autonomy and religious convictions is important.

Choice C rationale:

Asking the client to decide about the blood transfusion is the correct course of action. Since the client is able to respond to questions appropriately, they should be informed about their condition, the need for a blood transfusion, and the potential risks and benefits. This respects the client's autonomy while ensuring they have the necessary information to make an informed decision.

Choice D rationale:

Notifying the client's family immediately is not the best initial action. While involving the family is important, the client's own decision about the blood transfusion should take precedence, especially when they are conscious and able to make decisions for themselves.

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Correct Answer is C

Explanation

A. Volunteer to provide an inservice about infection control.While providing an inservice about infection control is important, it is not the immediate priority. The nurse needs to address the current situation to prevent potential contamination and infection spread.

B. Speak with the AP when he exits the room about the appropriate protocol.Speaking with the AP about the appropriate protocol is necessary, but it should be done after ensuring the immediate safety of the client and others. Delaying action could result in exposure to infectious agents.

C. Provide the appropriate PPE to the AP.This action addresses the immediate risk of infection transmission. By providing the appropriate PPE, the nurse ensures that the AP can safely continue their duties without putting themselves or the client at risk.

D. Notify the charge nurse about the AP's need for training.Notifying the charge nurse is important for long-term improvement, but it does not address the immediate risk. The nurse must first ensure that the AP is properly equipped to handle the current situation safely.

A. The laboratory technician restrains the arm of a client refusing to have blood drawn so that the specimen can be obtained. B. The primary health care provider tells a client that the nurse "does not know anything.” C. The nurse restrains a client at bedtime because the client gets up during the night and wanders around. D. The nurse tells a client that he will be tied down if he tries to get up from the chair.

Correct Answer is A

Explanation

Choice A rationale:

This situation represents an example of assault. Assault is the threat of bodily harm or unwanted physical contact, which creates an apprehension of fear in the victim. In this case, the laboratory technician's actions of restraining the client's arm against their will for blood drawing without consent is a form of assault as it involves an intentional act causing fear of harm.

Choice B rationale:

While telling a client that the nurse "does not know anything" is unprofessional and disrespectful, it doesn't constitute assault. This scenario is more related to issues of communication and respect rather than a direct threat of physical harm.

Choice C rationale:

Restraining a client at bedtime to prevent wandering is not assault. This scenario might involve ethical considerations and the appropriate use of restraints, but it doesn't meet the legal definition of assault, which involves a threat of physical harm.

Choice D rationale:

Threatening to tie down a client if they try to get up from the chair is an example of assault. This action creates an apprehension of fear in the client by implying a physically harmful act. It's a direct threat that falls under the category of assault.

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Naxlex Comprehensive Predictor Exams

A nurse sees an assistive personnel (AP) entering the room of a client who requires transmission-based precautions without using the appropriate personal protective equipment (PPE). Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is reviewing unintentional and intentional torts. Which of the following clinical situations would the nurse identify as an example of assault?

Correct Answer is A

Explanation

A nurse on the Medical-Surgical unit is assessing a patient's wound dressing, and observes a watery light red-pink drainage. The nurse should document this drainage as which of the following?

A nurse is educating a newly licensed nurse about ethical principles. Which of the following situations is an example of beneficence?

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?

A nurse is caring for a client who is scheduled for surgery. Before the client has signed the informed consent form, the client states, "I didn't really understand what that surgeon said." Which of the following actions should the nurse take?

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

The nurse in the trauma unit has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?