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 ["B","C","E","F"]

Explanation

A. Douching is not recommended during pregnancy as it can disrupt the natural balance of vaginal flora and increase the risk of infection.
B. Loose-fitting clothing allows for better air circulation and can help prevent discomfort and irritation, especially with increased sweating and vaginal discharge during pregnancy.

C. Flat or low-heeled shoes provide better support and stability, reducing the strain on the back and pelvis, which can alleviate backaches common during pregnancy.
D. Hot showers can exacerbate itching, especially if the skin is already irritated.

Lukewarm or cool showers are preferable for relieving itching.

E. Fried foods can contribute to heartburn and indigestion, which are common during pregnancy due to hormonal changes and increased pressure on the stomach from the growing uterus.
F. An abdominal support belt can help alleviate backaches by providing additional support to the abdomen and reducing strain on the back muscles.
G. Eating frequent, smaller meals throughout the day is recommended during pregnancy to help manage heartburn, prevent overeating, and maintain stable blood sugar levels.

A. A client who is scheduled for a colonoscopy and is taking sodium phosphate. B. A client who received a Mantoux test 48 hr ago and has an induration. C. A client who is taking bumetanide and reports an increase in urination D. A client who is taking warfarin and has started to breastfeed.

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.

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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 in an outpatient clinic is caring for a client. Exhibits Which of the following statements should the nurse include in the client's teaching? Select all that apply.

Correct Answer is ["B","C","E","F"]

Explanation

A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow-up care?

Correct Answer is A

Explanation

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