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:
The nurse is demonstrating the phase of nursing care known as "Implementation." During this phase, the nurse carries out the interventions and actions that were planned in the previous stages of the nursing process. In this scenario, applying warm compresses to the client's joint is a planned intervention that is being executed by the nurse.
Choice B rationale:
Planning is not the correct choice for this scenario. Planning is the phase of nursing care where the nurse sets goals, outcomes, and develops a plan of action based on the assessment data. It occurs before the implementation phase.
Choice C rationale:
Evaluation is not the correct choice for this scenario. Evaluation is the phase where the nurse assesses the outcomes of the interventions and determines whether the goals have been met. It comes after the implementation phase.
Choice D rationale:
Assessment is not the correct choice for this scenario. Assessment is the initial phase of the nursing process where the nurse collects data about the client's health status. It precedes the planning, implementation, and evaluation phases.
Correct Answer is A
Explanation
The correct answer is choice A. Transparent dressing.
Choice A rationale:
Transparent dressings are appropriate for stage I pressure ulcers. These dressings provide a moist environment that promotes healing and protects the wound from external contaminants. They are also transparent, allowing the nurse to monitor the wound without removing the dressing. As stage I pressure ulcers involve intact skin with non-blanchable redness, these dressings aid in preventing friction and shear forces that could exacerbate the injury.
Choice B rationale:
Alginate dressings (Choice B) are not suitable for stage I pressure ulcers. Alginate dressings are highly absorbent and are generally used for wounds with moderate to heavy exudate, such as infected wounds or those with necrotic tissue. They may not be the best choice for a stage I pressure ulcer, which is characterized by superficial skin involvement without exudate or necrosis.
Choice C rationale:
Hydrogel dressings (Choice C) are beneficial for wounds with minimal to no exudate, but they are more appropriate for partial-thickness wounds, burns, or dry wounds. They provide a moist environment and promote autolytic debridement. However, in the case of a stage I pressure ulcer, where the skin is intact and there is no exudate, hydrogel dressings may not be the ideal choice.
Choice D rationale:
Wet-to-dry gauze dressings (Choice D) involve placing moist saline gauze onto a wound bed and allowing it to dry before removal. This method is used for mechanical debridement of wounds with necrotic tissue, and it's not suitable for a stage I pressure ulcer. In fact, using wet-to-dry dressings on a superficial wound could cause trauma and hinder healing.
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