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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) Document the client's condition every 15 min: This is an appropriate guideline for the use of restraints. Regular monitoring and documentation are essential to ensure the client's safety and well-being, and every 15 minutes is a commonly recommended interval.

B) Attach the restraint to the bed's side rails: Restraints should not be attached to the side rails, as this can pose a risk of injury if the rails are moved. Instead, they should be secured to a stationary part of the bed frame.

C) Remove the client's restraint every 4 hr: This guideline is not appropriate. Restraints should be removed at least every 2 hours to assess the client's needs and allow for movement, unless otherwise specified by a healthcare provider.

D) Request a PRN restraint prescription for clients who are aggressive: Restraints should not be used as a PRN intervention. They require a specific order based on an assessment of the client’s condition and should only be used when less restrictive measures have failed. Regular assessment and a clear plan of care are critical for the appropriate use of restraints.

A. "I try to respond to the baby quickly so she doesn't cry very long." B. "I want to meet other parents to see if they are going through the same t C. "I think the baby should be sleeping through the night by now." D. "I have several friends who come by to help out with the baby."

Correct Answer is C

Explanation

A. "I try to respond to the baby quickly so she doesn't cry very long.": This statement reflects a positive parenting behavior, indicating the parent is attentive and responsive to the baby's needs, which is protective against child abuse.

B. "I want to meet other parents to see if they are going through the same thing.": This shows a desire for social support and connection, which is a healthy response to the challenges of parenting.

C. "I think the baby should be sleeping through the night by now.": This statement can indicate unrealistic expectations about infant behavior. It may suggest frustration and a lack of understanding of normal infant sleep patterns, which can increase stress and risk for abusive behaviors if the parent feels overwhelmed.

D. "I have several friends who come by to help out with the baby.": This indicates a support system, which is protective and beneficial for a new parent, reducing the likelihood of stress and potential abuse.

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A nurse is caring for a client who refuses a blood transfusion. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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