A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first?
Document the client's refusal in the medical record
Honor the client's decision to refuse the blood transfusion
Explore the client's reasons for refusing the treatment
Discuss the client's refusal with the provider
The Correct Answer is C
Explore the client's reasons for refusing the treatment.
- A. Documenting the client's refusal in the medical record is an important action, but not the first one. The nurse should first try to understand the client's perspective and address any concerns or misconceptions they might have about the blood transfusion. This choice is incorrect.
- B. Honoring the client's decision to refuse the blood transfusion is a respectful and ethical action, but not the first one. The nurse should first attempt to educate and persuade the client about the benefits and risks of the treatment, and respect their autonomy only after ensuring that they have made an informed decision. This choice is incorrect.
- C. Exploring the client's reasons for refusing the treatment is the first action that the nurse should take. The nurse should use effective communication skills to elicit the client's beliefs, values, fears, and preferences regarding the blood transfusion, and provide factual and evidencebased information to address any knowledge gaps or misconceptions. The nurse should also assess the client's decision-making capacity and determine if they are competent to refuse the treatment. This choice is correct.
- D. Discussing the client's refusal with the provider is an appropriate action, but not the first one. The nurse should first try to resolve the issue with the client directly, and involve the provider only if they are unable to do so or if there are legal or ethical implications that require further consultation. This choice is incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A is incorrect because the completion of the incident report should not be documented in the client's medical record, but in a separate file for quality improvement purposes.
B is correct because the time the medication was given is an essential fact related to the incident that should be documented in the client's medical record.
C is incorrect because the reason for the medication error should not be documented in the client's medical record, but in the incident report for analysis and prevention of future errors.
D is incorrect because the notification of the pharmacist should not be documented in the client's medical record, but in the incident report for follow-up and corrective actions.
Correct Answer is C
Explanation
Choice A rationale:
A random plasma glucose level of 176 mg/dL indicates high blood sugar at the time of the test. Random glucose levels are not ideal for assessing glycemic control as they can vary based on recent food intake and stressors.
Choice B rationale:
Triglyceride levels are not used to assess glycemic control. They measure the amount of triglycerides in the bloodstream and are related to lipid metabolism, not glucose control.
Choice C rationale:
HbA1c (glycated hemoglobin) is a long-term measure of blood glucose control. An HbA1c level of 6.8% indicates acceptable glycemic control in a person with diabetes. The normal range for HbA1c is typically less than 6.5%. This test reflects the average blood sugar level over the past 2-3 months, giving a better understanding of overall glucose control.
Choice D rationale:
Fasting blood glucose of 120 mg/dL is slightly elevated. While fasting blood glucose levels below 100 mg/dL are generally considered normal, levels between 100-125 mg/dL are considered prediabetic, and levels above 126 mg/dL on two separate occasions indicate diabetes. The result provided falls within the prediabetic range but does not indicate optimal glycemic control.
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