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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A: Covering the bowel with sterile gauze moistened with saline protects the exposed tissue and prevents it from drying out.
B: A low-Fowler's position with knees flexed reduces strain on the abdomen and minimizes further protrusion.
C: A side-lying position does not relieve strain on the abdominal incision as effectively as a low-Fowler’s position.
D: Retrieving the crash cart is unnecessary unless there is evidence of impending cardiopulmonary arrest.
E: Calling for assistance is essential to notify the surgical or medical team promptly.
F: Measuring inspiratory volume is irrelevant in this scenario and delays appropriate intervention.
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.
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