A nurse is preparing to transfer a client to surgery when the client states, "I have changed my mind and don't want to go through with this surgery." Which of the following actions should the nurse take?

Ask the family to speak to the client about their decision to refuse treatment.

Reinforce the importance of the surgical procedure for the client's recovery.

Notify the facility's risk management department about the client's decision.

Document the client's decision to refuse treatment in the medical record.

Answer and Explanation

The Correct Answer is D

Informed consent is an ongoing process, and clients retain the right to withdraw consent and refuse treatment at any time, even immediately before surgery. Nurses play a key role in advocating for client autonomy while ensuring that decisions are properly communicated and documented. When a client expresses refusal, the nurse must not coerce or pressure the client but instead ensure accurate documentation and notify the appropriate healthcare team members. Ethical and legal principles of autonomy guide the nurse’s response.

Rationale:
A. Asking the family to speak to the client about their decision is inappropriate because it may create undue pressure or coercion. The client has the legal right to make independent decisions regarding their care. Family involvement should support the client, not influence or override their autonomy.

B. Reinforcing the importance of the surgical procedure after the client has refused may be perceived as coercion. Although education is important during the consent process, once refusal is expressed, the nurse must respect the decision rather than attempt persuasion. This protects the client’s right to informed refusal.

C. Notifying the facility’s risk management department is not the immediate priority action in this situation. Risk management may become involved later for documentation or legal review, but the nurse’s primary responsibility is to respect and document the client’s decision and inform the surgical team.

D. Documenting the client’s decision to refuse treatment in the medical record is the correct nursing action. Accurate documentation ensures legal protection, continuity of care, and communication to the healthcare team. It also reflects respect for the client’s autonomy and ensures that the refusal is clearly recorded prior to surgery.

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Correct Answer is C

Explanation

Immunizations stimulate the immune system to develop protection against specific infectious diseases. After vaccination, mild and short-term reactions are common as the body mounts an immune response. These expected effects are generally self-limiting and indicate normal immune activation rather than complications. Guardians should be taught which reactions are normal and which require medical attention to ensure safe post-vaccination care.

Rationale:
A. Developing hives is not an expected reaction and may indicate a hypersensitivity or allergic reaction to the vaccine or its components. Hives are suggestive of an immune-mediated response that requires prompt medical evaluation rather than routine post-immunization care.

B. Hyperactivity is not a recognized reaction to immunizations. Behavioral changes such as hyperactivity are not associated with vaccine administration. Expected responses are typically localized discomfort or mild systemic symptoms, not significant behavioral alterations.

C. Tenderness at the injection site is an expected and common local reaction following immunization. This occurs due to localized inflammation as the immune system responds to the vaccine. Mild pain, redness, or swelling at the injection site is normal and typically resolves within a few days without intervention.

D. A temperature over 102.2°F is not considered a typical or expected response to routine immunizations. Although a low-grade fever may occur, high fever suggests a more significant reaction or possible infection that requires medical evaluation. Guardians should be advised to report high or persistent fevers to the healthcare provider.

A. "Increase your dietary intake by 500 calories per day." B. "Limit your caffeine intake to 700 milligrams per day." C. "Consume 600 micrograms of folic acid per day." D. "Eat 40 milligrams of protein-rich foods per day."

Correct Answer is C

Explanation

Nutrition during pregnancy is essential for fetal growth, neural tube development, and maternal physiological adaptation. In the first trimester, appropriate intake of key micronutrients supports organogenesis and reduces the risk of congenital anomalies. Folic acid is particularly important during early gestation because it helps prevent neural tube defects such as spina bifida. Dietary recommendations are based on established prenatal nutritional guidelines that ensure both maternal and fetal health.

Rationale:
A. Increasing dietary intake by 500 calories per day is not recommended at 12 weeks of gestation. Caloric requirements typically do not significantly increase until the second and third trimesters, when fetal growth accelerates. Early pregnancy focuses more on nutrient quality rather than increased caloric intake.

B. Limiting caffeine intake to 700 milligrams per day is incorrect because this amount is too high for pregnancy safety guidelines. Excess caffeine intake has been associated with risks such as miscarriage and low birth weight. One should limit caffeine to about 200 mg per day during pregnancy.

C. Consuming 600 micrograms of folic acid daily is the correct recommendation during pregnancy. Folic acid is essential for DNA synthesis and proper neural tube formation, especially during the first trimester. Adequate intake significantly reduces the risk of neural tube defects and supports healthy fetal development.

D. Eating 40 milligrams of protein-rich foods per day is incorrect because this amount is far below the recommended protein intake for pregnancy. Pregnant individuals require increased protein intake, typically about 60–75 grams per day, to support fetal tissue growth and maternal blood volume expansion. This value does not meet physiological needs.

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A nurse is preparing to transfer a client to surgery when the client states, "I have changed my mind and don't want to go through with this surgery." Which of the following actions should the nurse take?

Nursing Test Bank

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