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 B

Explanation

A) Schedule nursing staff training for infection control procedures: While staff training is important for reducing infection rates, it is a secondary step. First, understanding the underlying factors contributing to the increase in catheter infections is crucial.

B) Identify possible precipitating factors related to the infections: This action should be the priority. By identifying the specific causes or trends associated with the increase in infections, the charge nurse can target interventions more effectively and implement changes based on evidence.

C) Meet with providers to discuss measures to decrease the infections: Engaging providers is important, but it should occur after identifying the root causes. Once the contributing factors are understood, a more focused discussion can take place.

D) Revise the current policy for catheter care: While policy revision may be necessary, it is essential to first assess the current situation to understand why the infections are occurring. Without identifying the factors first, changes made may not address the actual issues at hand.

A. "Do you need information on hospice care?" B. "Do you need a prescription for an antianxiety medication?" C. "Would you like to talk to a counselor about advance directives?" D. "Would you like to speak to a spiritual advisor?"

Correct Answer is D

Explanation

A. "Do you need information on hospice care?" While hospice care is important for terminally ill patients, this question may not directly address the client's feelings of depression or their immediate emotional needs.

B. "Do you need a prescription for an antianxiety medication?" This statement may not be appropriate at this time, as it suggests a focus on medication rather than exploring the client's feelings. It’s important to first assess the client’s emotional needs and discuss therapy options.

C. "Would you like to talk to a counsellor about advance directives?" This question shifts the focus from the client's feelings of depression to advance care planning, which may not be the most relevant topic at this moment.

D. "Would you like to speak to a spiritual advisor?" This statement acknowledges the client's emotional state and offers a supportive option for exploring feelings of depression, which can be beneficial for those facing terminal illness. Spiritual support can provide comfort and help the client process their emotions during this difficult time.

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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 concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who has cancer and is terminally ill. The client reports feeling depressed. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

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