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 D

Explanation

A) Changes in appetite: While changes in appetite are important to assess, they are not the most immediate concern for a client with ALS who is experiencing weight loss. Appetite changes can contribute to weight loss, but other factors may be more critical.

B) Prescribed medications: Knowing the client’s prescribed medications is essential for overall care, but it is not the priority when addressing recent weight loss in a client with ALS. Medications can affect appetite and weight, but immediate physical concerns should be prioritized.

C) Daily fluid intake: Assessing daily fluid intake is important for hydration status, but it is not the priority in this scenario. Ensuring adequate fluid intake is necessary, but it does not directly address the potential complications related to weight loss in ALS.

D) Swallowing ability: Swallowing ability is the priority admission data to obtain for a client with ALS who has had recent weight loss. ALS can affect the muscles involved in swallowing, leading to dysphagia (difficulty swallowing). This can result in inadequate nutrition and hydration, as well as an increased risk of aspiration. Assessing swallowing ability helps identify the need for interventions such as dietary modifications, swallowing therapy, or alternative feeding methods to ensure the client’s safety and nutritional needs are met.

A. FHR baseline 170/min B. Early decelerations in the FHR C. Contractions lasting 80 seconds D. Temperature 37.4° C (99.3° F)

Correct Answer is A

Explanation

A) FHR baseline 170/min: A fetal heart rate (FHR) baseline of 170 beats per minute is considered tachycardia and can indicate fetal distress or maternal complications, such as fever or dehydration. This finding requires prompt reporting to the provider for further evaluation and intervention.

B) Early decelerations in the FHR: Early decelerations are typically benign and associated with head compression during contractions. They are not indicative of fetal distress and do not require immediate reporting.

C) Contractions lasting 80 seconds: While contractions that last longer than 90 seconds can indicate potential complications, 80 seconds is still within a manageable range. However, monitoring for patterns is essential, but it does not require urgent reporting unless there are other concerning signs.

D) Temperature 37.4° C (99.3° F): This temperature is within the normal range for a laboring woman and does not indicate infection or other complications. It is not a critical finding that necessitates reporting to the provider.

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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 D

Explanation

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Correct Answer is A

Explanation

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