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 C

Explanation

A) Perform exercises prior to bedtime: Engaging in vigorous exercise right before bedtime can actually be stimulating and may interfere with the ability to fall asleep. It is generally recommended to complete exercise earlier in the day to promote better sleep.

B) Stay in bed at least 1 hr if unable to fall asleep: This practice can lead to increased frustration and anxiety about sleep. Instead, it is often advised to get out of bed and engage in a calming activity until feeling sleepy again, which can help reduce sleep anxiety.

C) Eat a light snack before bedtime: Consuming a light snack can be beneficial, as certain foods (like those containing tryptophan) may promote sleepiness. It is important to avoid heavy meals, but a small snack can help some individuals feel more comfortable and ready for sleep.

D) Take a 1-hr nap during the day: While napping can be beneficial, a long nap may interfere with nighttime sleep, especially if taken later in the day. It’s generally better to keep naps short (20-30 minutes) and earlier in the day to avoid impacting nighttime sleep quality.

A. Premature ventricular contraction B. First-degree AV block C. Atrial fibrillation D. Sinus bradycardia

Correct Answer is B

Explanation

A) Premature ventricular contraction: A premature ventricular contraction (PVC) typically presents as an early heartbeat originating from the ventricles, often accompanied by a wide QRS complex. The heart rate in this case is regular at 69/min, and there is no indication of early beats, making this option unlikely.

B) First-degree AV block: A first-degree AV block is characterized by a prolonged PR interval greater than 0.20 seconds, which is noted at 0.24 seconds in this scenario. This indicates a delay in conduction through the AV node. While the heart rate is normal, the prolonged PR interval clearly suggests a first-degree AV block.

C) Atrial fibrillation: Atrial fibrillation typically presents with an irregularly irregular rhythm and variable heart rates. The client’s heart rate of 69/min is regular, and there is no mention of an irregular pulse or varying R-R intervals, making atrial fibrillation an unlikely diagnosis in this case.

D) Sinus bradycardia: Sinus bradycardia is defined as a heart rate of less than 60 beats per minute and is characterized by a normal PR interval. In this situation, the heart rate is 69/min, which does not meet the criteria for bradycardia, thus ruling out this option.

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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?

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