During a pre-surgical admission assessment, a client states. "I've told my surgeon that I am Jehovah's Witness and I won't accept a blood transfusion." Which statement by the nurse would be most appropriate?

"Tell me about your fear of receiving a blood transfusion."

"Your request to not receive a transfusion will be honored. Your consent is needed to administer blood or blood products."

"Are you sure? Please consider the risk you are taking if you refuse a blood transfusion."

"You don't need to worry about getting a blood transfusion. Blood loss is minimal with this procedure."

Answer and Explanation

The Correct Answer is B

A. Assuming the client’s decision is based on fear may feel dismissive of their beliefs.

B. Acknowledging and respecting the client’s decision while confirming their right to consent honors their autonomy and builds trust.

C. Questioning the client’s decision undermines their beliefs and autonomy.

D. Reassuring the client about blood loss dismisses their valid concerns about transfusion refusal.

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Correct Answer is C

Explanation

A. Increasing the infusion would worsen respiratory depression.

B. Supplemental oxygen is supportive but does not address the cause of respiratory depression.

C. Midazolam can cause respiratory depression, and flumazenil (a benzodiazepine antagonist) is the antidote; however, if naloxone is available, it may reverse sedation quickly in emergency scenarios.

D. While neurological assessment is vital, it does not address the immediate issue of respiratory compromise.

A. Continue monitoring the vitals B. inform the surgeon about the increase in temperature C. increase intravenous fluid rates D. inform the surgeon about the decrease in blood pressure

Correct Answer is A

Explanation

A. The changes in vital signs are within expected ranges post-procedure, so continued monitoring is appropriate.

B. A temperature increase to 99°F is not significant and does not require immediate reporting.

C. No signs of hypovolemia or dehydration warrant increasing IV fluids.

D. A blood pressure decrease to 112/72 mm Hg is minimal and not concerning.

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During a pre-surgical admission assessment, a client states. "I've told my surgeon that I am Jehovah's Witness and I won't accept a blood transfusion." Which statement by the nurse would be most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Exhibits A client is brought to post anesthesia care unit (PACU) after an invasive procedure. Based on the two sets of vital signs in the chart tab, which action is most appropriate by the nurse?

Correct Answer is A

Explanation

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