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 B

Explanation

A. Limiting intake of dairy products may not directly address stomatitis unless the client has an intolerance or allergy to dairy.
B. Using a soft-bristle toothbrush helps prevent trauma to the oral mucosa, which can exacerbate stomatitis. Gentle oral care with a soft toothbrush after meals helps maintain oral hygiene without causing further irritation.
C. Moistening lips with lemon-glycerin swabs may further irritate the oral mucosa due to the acidic nature of lemon.
D. Gargling with an alcohol-based mouthwash can exacerbate stomatitis and should be avoided due to its drying effect on oral tissues.

A. A client who is receiving heparin for deep-vein thrombosis. B. A client who is 1 day postoperative following a vertebroplasty. C. A client who has COPD and a respiratory rate of 44/min. D. A client who has cancer and a sealed implant for radiation therapy.

Correct Answer is B

Explanation

A: Heparin administration requires careful monitoring of clotting times, so discharging this client early may not be safe or appropriate.
B: A vertebroplasty is a procedure that injects cement into a fractured vertebra to help relieve pain and stabilize the spine. The recovery time for this procedure is usually short and the complications are rare.
C: This client has a respiratory rate suggestive of respiratory distress and may require immediate medical attention, hence early discharge is not an option.
D: The client with cancer and a sealed implant for radiation therapy may require ongoing monitoring and supportive care, so early discharge may not be advisable.

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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 providing teaching to a client who is undergoing radiation therapy and has stomatitis. Which of the following responses by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?

Correct Answer is B

Explanation

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