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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?

A.

Inform the client that the transfusion is mandatory.

B.

Notify risk management about the client's refusal.

C.

Document the client's refusal in the medical record.

D.

Suggest that the client explore alternative therapies.

Answer and Explanation

The Correct Answer is C

A.    Informing the client that the transfusion is mandatory disregards the client's autonomy and right to refuse treatment.
B.    While documenting the client's refusal is important, notifying risk management about the refusal is not necessary unless there are specific facility policies or legal requirements.
C.    Documenting the client's refusal in the medical record ensures that the refusal is properly recorded and communicated to the healthcare team, protecting both the client's autonomy and the healthcare provider.
D.    While it's important to respect the client's autonomy, suggesting alternative therapies may not be appropriate in this context and could undermine the client's decision-making process.
 


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Correct Answer is ["A","B","D","F","G","I","J"]

Explanation

Yellowing of the eyes could indicate hepatotoxicity, a serious adverse effect associated with some of the anti-tuberculosis medications, particularly rifampin.

Blurred vision could be a sign of optic neuritis, a rare but serious adverse effect associated with ethambutol.

Abdominal pain could indicate hepatitis or hepatotoxicity, which are potential adverse effects of anti-tuberculosis medications like isoniazid and rifampin.

Increased bruising could indicate thrombocytopenia, a serious adverse effect associated with some anti-tuberculosis medications, particularly rifampin.

Increased bleeding tendency could also indicate thrombocytopenia or other hematologic abnormalities.

Red/orange tint to urine could indicate rifampin-induced discoloration of bodily fluids, which is not harmful but can be alarming to patients.

Darkening of urine could also be a result of rifampin-induced discoloration. It's important to differentiate between this harmless side effect and hematuria, which could indicate a more serious issue.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

A. Applying lotion to the skin is contraindicated during phototherapy because it can interfere with the effectiveness of the therapy by blocking the light from reaching the skin. B. Supplementing feeding with sterile water is contraindicated because it can decrease the newborn's intake of breast milk or formula, which is essential for hydration and nutrition, especially during phototherapy. C. Breastfeeding is indicated and encouraged every 2 to 3 hours because it helps to maintain hydration and promotes bilirubin excretion, which can help in reducing jaundice levels. D. Covering the newborn's eyes with a shield is indicated during phototherapy to protect the eyes from the bright lights used in the treatment, which can potentially damage the retina and cause eye problems. E. Dressing the newborn in only a diaper is indicated during phototherapy to maximize the exposure of the skin to the light, which enhances the effectiveness of the treatment in reducing bilirubin levels.

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