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.

Notify risk management about the client's refusal.

Document the client's refusal in the medical record.

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 D

Explanation

A. The Sims position is a lateral position used for procedures such as rectal examinations and enemas and is not typically indicated for managing increased intracranial pressure.
B. The supine position may worsen increased intracranial pressure by increasing venous return and intracranial pressure.
C. The left lateral position may be used in specific circumstances, such as to relieve pressure on the vena cava in pregnancy, but it is not typically indicated for managing increased intracranial pressure.
D. Positioning the client in Low-Fowler's position (with the head of the bed elevated approximately 15-30 degrees) helps facilitate venous drainage from the brain, thereby reducing intracranial pressure. This position promotes optimal cerebral perfusion and helps manage increased intracranial pressure.

A. "I will place my baby in a forward-facing car seat in my back seat." B. "I can turn my baby's car seat around when she weighs 15 pounds." C. "I will position my baby at a 45-degree angle in the car seat." D. "I can place my baby in the front seat with the airbag turned off."

Correct Answer is C

Explanation

A. Placing a newborn in a forward-facing car seat is unsafe and not recommended due to the risk of injury in case of a crash.
B. Turning the baby's car seat around at 15 pounds is too early. Rear-facing car seats are recommended until the child reaches the weight or height limit set by the manufacturer.
C. Positioning the baby at a 45-degree angle in the car seat helps prevent airway obstruction and allows for proper breathing and spinal alignment.
D. Placing a baby in the front seat, even with the airbag turned off, is not recommended due to the risk of injury from airbag deployment.

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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

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Correct Answer is C

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