A nurse is caring for a client who refuses a blood transfusion. Which of the following actions should the nurse take?

Inform the client that the transfusion is mandatory.

Document the client's refusal in the medical record.

Notify risk management about the client's refusal.

Suggest that the client explore alternative therapies.

Answer and Explanation

The Correct Answer is B

A) Inform the client that the transfusion is mandatory: This approach is not appropriate, as it disregards the client's autonomy and right to make informed decisions about their own healthcare. Patients have the right to refuse treatment, including blood transfusions.

B) Document the client's refusal in the medical record: This is the correct action. It is essential to document the client's decision thoroughly, including the discussion surrounding the refusal and any information provided about the risks and benefits of the transfusion. This documentation protects both the client and the healthcare team.

C) Notify risk management about the client's refusal: While it may be necessary to inform risk management in certain cases, it is not a standard procedure for all refusals of treatment. The focus should be on respecting the client's wishes first and ensuring proper documentation.

D) Suggest that the client explore alternative therapies: While it is important to provide clients with information about their options, suggesting alternative therapies should not take precedence over respecting the client's decision. Instead, the nurse should ensure the client is fully informed about the implications of their refusal and provide support in understanding their choices.

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Correct Answer is A

Explanation

A) Assault:Assault refers to an intentional act that creates a reasonable apprehension of imminent harmful or offensive contact. In this scenario, the newly licensed nurse’s statement about inserting a urinary catheter if the client does not void can be perceived as a threat, causing the client to fear an unwanted procedure.

B) Libel:Libel involves making false, defamatory statements in written form that harm someone’s reputation. This option is not applicable in this context, as the nurse’s statement was verbal and did not involve written defamation.

C) Negligence:Negligence occurs when a healthcare provider fails to meet the standard of care, resulting in harm to the client. While the nurse’s statement may be inappropriate, it does not constitute negligence, as it does not involve a breach of the standard of care leading to harm.

D) Battery:Battery involves intentional physical contact with another person without their consent. In this case, the nurse has not yet performed any physical act, so battery has not occurred. The threat alone constitutes assault, not battery.

A. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field. B. Open the outermost flap of the sterile kit toward the body. C. Place the cap from the solution sterile side up on a clean surface. D. Set up the sterile field 5 cm (2 in) below waist level.

Correct Answer is C

Explanation

A. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field: This action is not appropriate, as sterile items should be placed at least 2.5 cm (1 in) away from the edge of the sterile field to maintain sterility and prevent contamination.

B. Open the outermost flap of the sterile kit toward the body: The correct practice is to open the outermost flap away from the body. This technique helps prevent any contaminants from the nurse's clothing or body from falling into the sterile field.

C. Place the cap from the solution sterile side up on a clean surface: This is the correct action. By placing the cap sterile side up, the nurse minimizes the risk of contamination to the sterile solution and maintains the integrity of the sterile field.

D. Set up the sterile field 5 cm (2 in) below waist level: Setting up a sterile field below waist level increases the risk of contamination, as it may come into contact with non-sterile surfaces. The sterile field should be set up at waist level or higher to maintain sterility.

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A nurse is caring for a client who refuses a blood transfusion. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is observing a newly licensed nurse provide care for a client who is postoperative. The newly licensed nurse tells the client that she will insert a urinary catheter if the client will not void. Which of the following torts should the charge nurse identify as having occurred?

Correct Answer is A

Explanation

A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

Correct Answer is C

Explanation

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