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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Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A. Keeping objects in the same place help maintain a safe environment and independence for a client with vision loss.
B. When caring for a client with vision loss, the nurse should avoid approaching the client from the side since it may startle them.
C. Providing high-wattage lighting can improve visibility for clients with partial vision loss. Adequate lighting reduces shadows and enhances contrast, making it easier for the client to see their surroundings

D. Allowing extra time for tasks helps orient them to the nurse's presence and facilitates communication.
E. While gentle touch can be a way to announce presence, it is better to verbally announce oneself first to avoid startling the client, particularly if they are not expecting contact.

A. Facilitate the client's problem-solving skills. B. Establish the responsibilities of the nurse and client. C. Assist the client in expressing alternative behaviors. D. Determine previous coping skills used by the client.

Correct Answer is B

Explanation

A: Facilitating problem-solving skills is typically more relevant during the working phase of the therapeutic relationship, not the orientation phase.
B: During the orientation phase, establishing clear roles and responsibilities helps set expectations and boundaries for the therapeutic relationship.
C: Assisting the client in expressing alternative behaviors is also more relevant during the working phase when exploring and implementing change.
D: Determining previous coping skills is important but typically occurs during the assessment phase, which precedes the orientation phase of the therapeutic relationship.

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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 nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship?

Correct Answer is B

Explanation

A nurse is caring for a client who has a new diagnosis of schizophrenia and a prescription for an antipsychotic medication. The nurse should recognize that which of the following indicates an adverse effect that must be reported to the provider?

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?

A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?

A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?

A nurse is assessing a client who has histrionic personality disorder. Which of the following manifestations should the nurse expect?

A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?