A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first?
Document the client's refusal in the medical record
Honor the client's decision to refuse the blood transfusion
Explore the client's reasons for refusing the treatment
Discuss the client's refusal with the provider
The Correct Answer is C
Explore the client's reasons for refusing the treatment.
- A. Documenting the client's refusal in the medical record is an important action, but not the first one. The nurse should first try to understand the client's perspective and address any concerns or misconceptions they might have about the blood transfusion. This choice is incorrect.
- B. Honoring the client's decision to refuse the blood transfusion is a respectful and ethical action, but not the first one. The nurse should first attempt to educate and persuade the client about the benefits and risks of the treatment, and respect their autonomy only after ensuring that they have made an informed decision. This choice is incorrect.
- C. Exploring the client's reasons for refusing the treatment is the first action that the nurse should take. The nurse should use effective communication skills to elicit the client's beliefs, values, fears, and preferences regarding the blood transfusion, and provide factual and evidencebased information to address any knowledge gaps or misconceptions. The nurse should also assess the client's decision-making capacity and determine if they are competent to refuse the treatment. This choice is correct.
- D. Discussing the client's refusal with the provider is an appropriate action, but not the first one. The nurse should first try to resolve the issue with the client directly, and involve the provider only if they are unable to do so or if there are legal or ethical implications that require further consultation. This choice is incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- A. Autonomy is the ethical principle that respects the right of clients to make their own decisions and choices regarding their health care. Informed consent is a process that ensures that clients are fully informed of the benefits, risks, alternatives, and consequences of a proposed treatment or procedure, and that they voluntarily agree to it.
- B. Nonmaleficence is the ethical principle that obliges health care providers to do no harm to clients, either intentionally or unintentionally. Informed consent does not directly promote this principle, although it may help to prevent harm by disclosing potential risks and complications.
- C. Justice is the ethical principle that requires fair and equal treatment of all clients, regardless of their personal characteristics, preferences, or values. Informed consent does not directly promote this principle, although it may help to ensure that clients are not coerced or manipulated into accepting a treatment or procedure that they do not want or need.
- D. Fidelity is the ethical principle that requires health care providers to be faithful and loyal to their clients, and to honor their commitments and promises. Informed consent does not directly promote this principle, although it may help to establish trust and rapport between clients and providers.
Correct Answer is B
Explanation
A. "Limit each of the client's visitors to 2 hr per day."
This is incorrect. While visitors should have their exposure limited, the recommended duration is typically much shorter (around 30 minutes to 1 hour), not 2 hours. This is to reduce radiation exposure.
B. "Instruct visitors to stay 1 m (3.3 feet) away from the client."
This is correct. For clients undergoing brachytherapy with a low-dose radiation implant, visitors should maintain a safe distance, usually at least 6 feet (1.8 meters), but some guidelines may state a minimum of 3.3 feet (1 meter) for safety, depending on the specific radiation dose and facility protocols.
C. "Attach a dosimeter to the client's gown."
This is incorrect. Dosimeters are generally worn by healthcare providers, not the patient. The primary purpose is to measure the radiation exposure of healthcare workers, not the patient.
D. "Strain the client's urine."
This is incorrect. Straining urine is not necessary for a patient undergoing brachytherapy. However, it may be important to monitor the urine for signs of radiation leakage, but straining is not a routine part of care.
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