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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Adding medication directly to enteral feeding can cause clogging of the tube and interfere with medication absorption.
B. Flushing with only 5 mL of water is insufficient. Typically, the tube should be flushed with 15-30 mL of water before and after administering each medication to ensure the tube is clear and to prevent clogging.
C. Dissolving medications together may lead to drug interactions or alterations in drug absorption and should be avoided.
D. Using a syringe to allow the medications to flow by gravity ensures that the medications are delivered safely and steadily. After each medication is administered, the tube should be flushed with water to ensure it is clear and to prevent interactions between different medications.
Correct Answer is D
Explanation
A. Ketorolac is an NSAID that carries a risk of gastrointestinal bleeding and is contraindicated in clients with cholelithiasis due to its potential to cause biliary colic.
B. Omeprazole is a proton pump inhibitor used to reduce gastric acid secretion and prevent ulcers but does not provide immediate pain relief.
C. Metoclopramide is a prokinetic agent that helps with gastric emptying and may be used to relieve symptoms such as nausea and vomiting but is not indicated for pain relief.
D. Acetaminophen is a suitable PRN pain medication for a client experiencing moderate abdominal pain due to cholelithiasis. It provides effective analgesia without exacerbating symptoms or causing adverse effects on the gastrointestinal system, which is crucial for clients with gallstone-related pain.
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