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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Repositioning the client every 3 hours is a crucial intervention to prevent skin breakdown in older adults who are immobile or have limited mobility. Prolonged pressure on certain areas can lead to ischemia and tissue damage, particularly over bony prominences. Repositioning helps to distribute pressure evenly, maintain circulation, and reduce the risk of pressure ulcers.
Choice B rationale:
Massage of bony prominences is not recommended as a preventive measure for skin breakdown. Massaging these areas can actually cause friction and shear forces, leading to further damage to the delicate skin of older adults. Gentle repositioning and maintaining proper skin hygiene are more effective strategies.
Choice C rationale:
While a diet high in protein is important for overall health, it is not a direct intervention for maintaining the integrity of the client's skin. Protein is necessary for wound healing and tissue repair, but it doesn't address the primary concern of preventing skin breakdown due to pressure.
Choice D rationale:
Applying cornstarch to keep the skin dry is not a recommended practice for preventing skin breakdown. Excessive moisture can contribute to skin breakdown, but cornstarch may not be the best solution. Proper hygiene, gentle cleansing, and appropriate use of moisture-barrier products are more effective in maintaining skin integrity.
Correct Answer is C
Explanation
Choice A rationale:
Encouraging the client to ambulate frequently is important for preventing complications associated with immobility, such as deep vein thrombosis and muscle atrophy. However, it is not a direct intervention for promoting the thinning of respiratory secretions.
Choice B rationale:
Encouraging the client to increase fluid intake is a valuable intervention to help thin respiratory secretions. However, the most effective method mentioned here is the use of the incentive spirometer, which directly assists the client in taking deep breaths and enhancing lung function.
Choice C rationale:
Encouraging regular use of the incentive spirometer is a crucial intervention for promoting the thinning of respiratory secretions. Incentive spirometry helps prevent atelectasis (collapse of lung tissue) and promotes deep breathing, which aids in clearing secretions and maintaining lung health.
Choice D rationale:
Encouraging coughing and deep breathing is generally important for maintaining lung health and preventing complications like pneumonia. However, the specific action of using the incentive spirometer is more targeted and effective for promoting respiratory secretion clearance in clients with pneumonia.
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