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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: A client who is scheduled for a colonoscopy and is taking sodium phosphate requires follow-up care because sodium phosphate can cause colonic mucosal damage and electrolyte imbalances that may affect the safety and accuracy of the colonoscopy. Sodium phosphate is a bowel preparation agent that empties the colon before the procedure, but it can also cause dehydration, kidney injury, and cardiac arrhythmias.
B: Induration following a Mantoux test indicates a reaction that may suggest tuberculosis exposure, but this is an expected result that requires assessment rather than immediate follow-up.
C: Bumetanide is a diuretic, and an increase in urination is an expected effect of this medication.
D: Warfarin is considered safe during lactation since it is not excreted in breastmilk to any measurable degree.
Correct Answer is C
Explanation
A. Cleaning a cat's litter box can expose pregnant individuals to toxoplasmosis, a risk factor for congenital birth defects.
B. Antibiotics are not effective against viral infections and should not be used unnecessarily.
C. Waiting until the chickenpox sores have crusted reduces the risk of transmission, indicating an understanding of infection prevention. This statement reflects appropriate knowledge about infectious disease control during pregnancy.
D. While handwashing is important, the recommended duration is at least 20 seconds, and hot water is not necessary for effective hand hygiene.
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