Try Naxlex NCLEX-RN (Free-Trial)

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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale:

Insomnia is a common side effect of sertraline and many other antidepressant medications. It is not indicative of serotonin syndrome, a potentially life-threatening condition characterized by excessive serotonin levels in the brain.

Choice B rationale:

Constipation is a side effect of some antidepressant medications, including sertraline. It is not a symptom of serotonin syndrome, which presents with a combination of symptoms such as confusion, agitation, rapid heart rate, dilated pupils, muscle rigidity, and high body temperature.

Choice C rationale:

Dry mouth is another common side effect of sertraline and many other medications. While uncomfortable, it is not a sign of serotonin syndrome. Symptoms of serotonin syndrome are neurological and autonomic, involving changes in mental status, muscle activity, and vital signs.

Choice D rationale:

Excessive sweating, also known as diaphoresis, can be a symptom of serotonin syndrome. Other symptoms might include agitation, tremor, hyperreflexia, fever, dilated pupils, and diarrhea. If a patient experiences these symptoms while taking sertraline, it could indicate serotonin syndrome and should be reported immediately for medical evaluation.

A. Turn on the faucets in the client's sink. B. Tell the client to gently stroke her lower abdomen. C. Instruct the client to lean slightly backward. D. Pour cool water over the client's perineum.

Correct Answer is B

Explanation

Choice B rationale:

Instructing the client to gently stroke her lower abdomen is the appropriate action in this situation. Gentle stroking or tapping on the lower abdomen can stimulate the bladder reflex and promote urination. This technique can help clients who have difficulty voiding, especially when using a bedpan. It encourages relaxation of the pelvic muscles, making it easier for the client to urinate.

Choice A rationale:

Turning on the faucets in the client's sink is not a recommended action for promoting urination. While the sound of running water can sometimes trigger the need to urinate, it may not be effective for every individual. Moreover, this action may not be practical or feasible in all healthcare settings.

Choice C rationale:

Instructing the client to lean slightly backward is not an appropriate action for promoting urination. Leaning backward can put pressure on the bladder, which may make it more challenging for the client to urinate. Encouraging relaxation and using techniques like gentle abdominal stroking are more effective in this situation.

Choice D rationale:

Pouring cool water over the client's perineum is not a recommended action for promoting urination. While some individuals find warm water soothing and relaxing, pouring cold water may cause discomfort and stress, making it even more difficult for the client to urinate. Gentle stimulation and relaxation techniques are generally more effective.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a new prescription for sertraline to treat depression.For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?

Correct Answer is D

Explanation

A nurse is caring for a female client who requires bed rest and reports difficulty urinating into a bedpan.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?

A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease.Which of the following foods should the nurse recommend including in the preschooler's diet?

A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?

A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?

A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy. Exhibits Complete the following sentence by using the lists of options. The client is at the highest risk for developing hypocalcemia evidenced by the

A nurse is caring for a client who is preoperative for cataract removal.Which of the following statements by the client indicates an understanding of the procedure?

A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia.Which of the following actions should the nurse plan to take?