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.
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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Related Questions
Correct Answer is D
Explanation
A. Although activity is encouraged, clients with acute heart failure may require rest to minimize cardiac demand.
B. Clients with acute heart failure typically need fluid restrictions, not boluses, which could exacerbate heart failure symptoms.
C. A low-sodium diet is usually recommended for heart failure clients to help manage fluid retention, not a high-sodium diet.
D. Enalapril is an ACE inhibitor often prescribed for clients with heart failure as it helps reduce blood pressure and decrease the workload on the heart.
Correct Answer is B
Explanation
A: Facilitating problem-solving skills is typically more relevant during the working phase of the therapeutic relationship, not the orientation phase.
B: During the orientation phase, establishing clear roles and responsibilities helps set expectations and boundaries for the therapeutic relationship.
C: Assisting the client in expressing alternative behaviors is also more relevant during the working phase when exploring and implementing change.
D: Determining previous coping skills is important but typically occurs during the assessment phase, which precedes the orientation phase of the therapeutic relationship.
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