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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) "I can use natural-skin condoms to prevent sexually transmitted infections.": This statement is incorrect. Natural-skin condoms (made from lambskin) are effective for pregnancy prevention but do not provide protection against sexually transmitted infections (STIs). For STI prevention, latex or polyurethane condoms should be used.
B) "I can store the condoms in the drawer of my nightstand.": This statement demonstrates an understanding of proper condom storage. Storing condoms in a cool, dry place, such as a drawer, helps prevent damage from heat and friction, ensuring their effectiveness when used.
C) "I can use petroleum jelly as a lubricant with the condom.": This statement is incorrect because petroleum jelly can degrade latex condoms, increasing the risk of breakage. Water-based or silicone-based lubricants are recommended for use with latex condoms to maintain their integrity.
D) "I can re-use the condom one time after initial use.": This statement is incorrect. Condoms are designed for single use only and should not be re-used. Re-using a condom increases the risk of breakage and reduces effectiveness in preventing pregnancy and STIs.
Correct Answer is D
Explanation
A) "Limit the time your infant feeds to 10 minutes on each breast.": Limiting feeding time can be detrimental, as infants often need varying lengths of time to effectively nurse. It's essential to allow the infant to feed as long as they need to ensure adequate milk intake and to stimulate milk production.
B) "Supplement breastfeeding with water every 12 hours.": Breastfed infants typically do not need supplemental water in the first six months of life, as breast milk provides all necessary hydration and nutrients. Offering water can fill the infant's stomach and reduce breastfeeding frequency, impacting nutrition.
C) "Begin each feeding using the same breast.": It's common to start with one breast and then offer the second breast if the infant is still hungry. However, alternating which breast to start with at each feeding can help maintain an even milk supply and prevent engorgement.
D) "Offer your infant the breast when he shows signs of hunger.": This is the most appropriate recommendation. Recognizing and responding to hunger cues—such as rooting, smacking lips, or increased alertness—promotes successful breastfeeding and ensures that the infant is receiving adequate nutrition.
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