A nurse is preparing to transfer a client to surgery when the client states, "I have changed my mind and don't want to go through with this surgery." Which of the following actions should the nurse take?

Reinforce the importance of the surgical procedure for the client's recovery.

Document the client's decision to refuse treatment in the medical record.

Notify the facility's risk management department about the client's decision.

Ask the family to speak to the client about their decision to refuse treatment.

Answer and Explanation

The Correct Answer is B

Clients have the legal and ethical right to refuse medical treatment at any time, even after providing informed consent, as long as they are competent to make decisions. When a client expresses refusal of a procedure, the nurse must prioritize respecting autonomy while ensuring the provider is informed so that further discussion and assessment can occur. Proper documentation is essential to accurately reflect the client’s decision and support continuity of care. Nursing actions must remain non-coercive and centered on patient rights.

Rationale:
A. Reinforcing the importance of the surgical procedure may be perceived as coercive and may violate the client’s right to refuse treatment. While education is important, the immediate priority is to respect the client’s expressed decision and ensure it is communicated appropriately. The nurse should not attempt to persuade the client after a clear refusal has been stated.

B. Documenting the client’s decision to refuse treatment is correct because it provides an accurate legal record of the client’s expressed wishes. In situations involving procedures such as surgery, documentation ensures continuity of care and protects both the client’s rights and the healthcare team. Informed refusal is treated with the same seriousness as informed consent.

C. Notifying risk management is not the immediate nursing action. While risk management may become involved in complex legal or ethical cases, the first priority is to document the refusal and notify the provider. Escalation to administrative departments is secondary to direct clinical communication and documentation.

D. Asking the family to speak to the client is inappropriate because it may pressure or coerce the client into changing their decision. The client’s autonomy must be respected, and decisions should not be influenced by family members unless the client requests their involvement. The nurse must avoid shifting decision-making responsibility away from the competent client.

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Correct Answer is B

Explanation

Dietary management of hypertension often includes sodium restriction, such as a 2-gram sodium diet, to help reduce fluid retention and lower blood pressure. Sodium is commonly found in processed, cured, and preserved foods, while natural whole foods tend to contain minimal amounts. Clients are encouraged to choose fresh or minimally processed options to maintain blood pressure control and reduce cardiovascular risk. Understanding food sources of hidden sodium is essential for effective dietary compliance.

Rationale:
A. Hot dogs are highly processed meats that contain significant amounts of sodium used for preservation and flavor enhancement. They are considered one of the highest sodium-containing foods and are not appropriate for a low-sodium diet. Regular consumption can contribute to fluid retention and worsening hypertension.

B. Frozen fruit is generally low in sodium, especially when it is plain and without added sauces or preservatives. In the context of a 2-gram sodium diet, frozen fruit is an appropriate choice because it is minimally processed and retains its natural nutrient profile. It is one of the safest options among the listed foods for sodium restriction.

C. Salad dressings often contain high levels of sodium, along with added preservatives and flavor enhancers. Even small servings can significantly contribute to daily sodium intake. Many commercial dressings are not suitable for clients on restricted sodium diets unless specifically labeled low-sodium.

D. Cheddar cheese contains moderate to high amounts of sodium due to its processing and aging methods. Dairy products like processed cheeses are common hidden sources of sodium in the diet. Regular consumption may interfere with sodium restriction goals in hypertensive clients.

A. Non-pitting bilateral peripheral edema B. Oral temperature of 38.8° C (101.8° F) C. Scant lochia rubra on the perineal pad D. Fundus is located 2 cm (0.4 in) below the level of the umbilicus

Correct Answer is B

Explanation

Postpartum assessment within the first 24–48 hours focuses on identifying early complications such as hemorrhage and infection. Mild temperature elevations can be expected due to breast engorgement or dehydration, but significant fever is abnormal and may indicate infection such as endometritis or wound infection. Nurses must differentiate normal physiological postpartum changes from signs that require urgent escalation. Early detection is critical to prevent systemic infection and sepsis.

Rationale:
A. Non-pitting bilateral peripheral edema is a common physiological finding in the postpartum period due to fluid shifts and mobilization of extracellular fluid accumulated during pregnancy. It is typically self-limiting and not indicative of infection or acute complications. Monitoring and reassurance are usually sufficient.

B. An oral temperature of 38.8°C (101.8°F) is abnormal and requires immediate reporting because it may indicate postpartum infection such as endometritis or mastitis. In conditions like Postpartum infection, fever at this level suggests a significant inflammatory or infectious process requiring prompt evaluation and treatment.

C. Scant lochia rubra at 24 hours postpartum is a normal finding. Early postpartum bleeding is expected to be bright red and gradually decrease over time. Scant amount indicates appropriate uterine involution and does not suggest complications.

D. A fundus located 2 cm below the umbilicus is an expected postpartum finding. The uterus typically descends approximately 1 cm per day after birth as involution occurs. This indicates normal uterine contraction and recovery.

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A nurse is preparing to transfer a client to surgery when the client states, "I have changed my mind and don't want to go through with this surgery." Which of the following actions should the nurse take?

Nursing Test Bank

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