A nurse is caring for a client who is scheduled for a procedure, but the client states that they no longer want to undergo the procedure. Which of the following actions should the nurse take?
Explain that the treatment is both safe and therapeutic.
Tell the client that the procedure is necessary.
Notify the client's loved ones of the client's refusal of the procedure.
Inform the client they have the right to refuse treatment.
The Correct Answer is D
A. Explain that the treatment is both safe and therapeutic: Providing reassurance about the safety and effectiveness of the procedure may be informative, but it can unintentionally pressure the client to consent. It does not respect the client’s autonomy or support their right to make independent healthcare decisions.
B. Tell the client that the procedure is necessary: Telling the client a procedure is necessary can sound coercive and may disregard their legal and ethical right to refuse treatment. Nurses must prioritize respecting the client's decisions, even if those decisions involve refusing recommended medical care.
C. Notify the client's loved ones of the client's refusal of the procedure: Informing family members without the client’s consent may breach confidentiality and is not appropriate unless the client is unable to make informed decisions. Client autonomy must be preserved, and their refusal should be respected unless there is an immediate risk of harm.
D. Inform the client they have the right to refuse treatment: Clients have the legal and ethical right to refuse any medical intervention, even if it is life-sustaining. The nurse’s role includes advocating for the client’s autonomy, ensuring informed consent, and supporting their decision without judgment or pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The stoma protrudes slightly from the abdomen: A stoma that protrudes slightly (about 1–2 cm) above the skin surface is normal and indicates healthy placement. This finding does not require reporting.
B. The stoma bleeds lightly when touched: Light bleeding with gentle palpation or cleaning is common due to the stoma’s rich blood supply and is generally not concerning unless bleeding is excessive.
C. The stoma is draining a small amount of liquid stool: Liquid stool drainage is expected from a colostomy, especially in the early postoperative period. This is a normal finding that does not require reporting.
D. The stoma appears dark in color: A dark, dusky, or black stoma indicates compromised blood flow and possible ischemia or necrosis. This is a serious finding that requires immediate reporting to prevent further complications.
Correct Answer is A
Explanation
A. Leave the needle in place for 10 seconds after the injection: Leaving the needle in place for approximately 10 seconds after administering a subcutaneous injection helps ensure full delivery of the medication and reduces the chance of medication leakage at the injection site.
B. Use a 5-inch needle for the injection: A 5-inch needle is excessively long for subcutaneous injections and would likely penetrate muscle tissue, increasing the risk of injury or incorrect medication administration. Subcutaneous injections typically require a needle length between ⅜ and ⅝ inch.
C. Inject the medication using the Z-track technique: The Z-track technique is used for intramuscular injections to minimize medication leakage and reduce irritation. It is not appropriate for subcutaneous injections, which are administered into the fatty layer beneath the skin, not deep muscle tissue.
D. Insert the syringe at a 15° angle during injection: A 15° angle is used for intradermal injections. Subcutaneous injections should be administered at a 45° to 90° angle depending on the client’s body mass to ensure the medication is delivered into the subcutaneous tissue, not the dermis or muscle.
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