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.

Notify risk management about the client's refusal.

Document the client's refusal in the medical record.

Suggest that the client explore alternative therapies.

Answer and Explanation

The Correct Answer is C

A.   Informing the client that the transfusion is mandatory disregards the client's autonomy and right to refuse treatment.
B.   While documenting the client's refusal is important, notifying risk management about the refusal is not necessary unless there are specific facility policies or legal requirements.
C.   Documenting the client's refusal in the medical record ensures that the refusal is properly recorded and communicated to the healthcare team, protecting both the client's autonomy and the healthcare provider.
D.   While it's important to respect the client's autonomy, suggesting alternative therapies may not be appropriate in this context and could undermine the client's decision-making process.

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Correct Answer is C

Explanation

A. Eating a meal before postural drainage could increase the risk of aspiration during the procedure.
B. Completing oral hygiene is good practice but not directly related to postural drainage.
C. Albuterol can help open the airways, making the postural drainage process more effective.
D. Pancrelipase is a medication to aid in digestion and is not directly related to the initiation of postural drainage.

A. Direct statements to the interpreter. B. Speak in a normal voice at a natural pace. C. Pause in the middle of sentences. D. Use gestures when speaking with the client.

Correct Answer is B

Explanation

A. Directing statements to the interpreter rather than the client can create a communication barrier and undermine the client's autonomy and involvement in the conversation.
B. Speaking in a normal voice at a natural pace allows the interpreter to accurately convey the message to the client without feeling rushed or overwhelmed, facilitating effective communication.
C. Pausing in the middle of sentences can disrupt the flow of communication and make it difficult for the interpreter to accurately translate the message.
D. While gestures can complement verbal communication, relying solely on gestures may lead to misinterpretation or misunderstanding, especially if cultural differences exist between the nurse, client, and interpreter.

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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 an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?

Correct Answer is C

Explanation

A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter?

Correct Answer is B

Explanation

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