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.
Document the client's refusal in the medical record.
Notify risk management about the client's refusal.
Suggest that the client explore alternative therapies.
The Correct Answer is B
A) Inform the client that the transfusion is mandatory: This approach is not appropriate, as it disregards the client's autonomy and right to make informed decisions about their own healthcare. Patients have the right to refuse treatment, including blood transfusions.
B) Document the client's refusal in the medical record: This is the correct action. It is essential to document the client's decision thoroughly, including the discussion surrounding the refusal and any information provided about the risks and benefits of the transfusion. This documentation protects both the client and the healthcare team.
C) Notify risk management about the client's refusal: While it may be necessary to inform risk management in certain cases, it is not a standard procedure for all refusals of treatment. The focus should be on respecting the client's wishes first and ensuring proper documentation.
D) Suggest that the client explore alternative therapies: While it is important to provide clients with information about their options, suggesting alternative therapies should not take precedence over respecting the client's decision. Instead, the nurse should ensure the client is fully informed about the implications of their refusal and provide support in understanding their choices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Take a hot shower every day: This is a beneficial nonpharmacological pain management technique for clients with osteoarthritis. Warm water can help relax muscles and soothe joint stiffness, providing relief from pain.
B. Limit dietary intake of phosphorus: This is not directly related to pain management in osteoarthritis. While managing overall nutrition is important, phosphorus specifically does not need to be limited unless there are other underlying health conditions.
C. Place a large pillow under the knees when sleeping: This instruction may not be optimal. While some support can be helpful, using a pillow under the knees can cause misalignment of the spine. A more neutral sleeping position is generally recommended.
D. Place an ice pack directly on the skin of the affected joints: Applying ice directly to the skin can cause frostbite or skin damage. It's better to use a cloth or towel as a barrier when applying an ice pack to avoid direct contact and protect the skin.
Correct Answer is A
Explanation
A. "Information Technology will install a firewall to secure client information.": This statement is appropriate as it highlights the importance of cybersecurity measures, such as firewalls, in protecting client information within a computerized documentation system.
B. "Documentation of sensitive material is performed by the charge nurse.": This statement is misleading. While charge nurses may have responsibilities for certain documentation, all licensed nurses are responsible for accurately documenting sensitive materials related to their own patient care.
C. "You will be given access to the medical records of every client in the facility.": This is incorrect. Access to client medical records should be based on the nurse's role and the specific clients they are caring for, adhering to confidentiality and privacy policies.
D. "You will be asked to change your password once per year.": This is not sufficient for maintaining security. Best practices typically recommend changing passwords more frequently (e.g., every 3-6 months) to enhance security and protect sensitive information.
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