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. Place the client in Trendelenburg position: This position helps relieve pressure on the umbilical cord, potentially improving blood flow to the fetus. It is an appropriate immediate intervention for a prolapsed cord.

B. Apply fundal pressure: This is contraindicated in cases of cord prolapse as it can exacerbate the situation by pushing the presenting part further down and increasing pressure on the cord.

C. Loosely wrap the cord with petroleum gauze: While protecting the cord is important, simply wrapping it does not address the immediate need to relieve pressure and restore blood flow to the fetus.

D. Evaluate uterine tone: While assessing uterine tone is important during labor, the immediate priority when a prolapsed cord is noted is to relieve pressure on the cord to prevent fetal compromise. Therefore, this step should not be the first action taken.

A. "I will need to keep my hand elevated above my heart for several days." B. "I should expect numbness and tingling in my hand." C. "I should not use my affected hand for 4 to 6 weeks." D. "I can apply heat for the first 24 hours to minimize the pain in my hand."

Correct Answer is A

Explanation

A) “I will need to keep my hand elevated above my heart for several days.”: Elevating the hand above the heart helps reduce swelling and pain after surgery. This practice is crucial for promoting proper healing and minimizing discomfort.

B) “I should expect numbness and tingling in my hand.”: Numbness and tingling are not expected outcomes and could indicate complications. These symptoms should be reported to the healthcare provider for further evaluation.

C) “I should not use my affected hand for 4 to 6 weeks.”: Complete restriction of hand use for 4 to 6 weeks is unnecessary and could lead to stiffness and decreased function. Gradual use and movement are encouraged to aid recovery.

D) “I can apply heat for the first 24 hours to minimize the pain in my hand.”: Applying heat in the first 24 hours can increase swelling and should be avoided. Cold therapy is recommended initially to reduce inflammation and pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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