During a pre-surgical admission assessment, a client states. "I've told my surgeon that I am Jehovah's Witness and I won't accept a blood transfusion." Which statement by the nurse would be most appropriate?
"Tell me about your fear of receiving a blood transfusion."
"Your request to not receive a transfusion will be honored. Your consent is needed to administer blood or blood products."
"Are you sure? Please consider the risk you are taking if you refuse a blood transfusion."
"You don't need to worry about getting a blood transfusion. Blood loss is minimal with this procedure."
The Correct Answer is B
A. Assuming the client’s decision is based on fear may feel dismissive of their beliefs.
B. Acknowledging and respecting the client’s decision while confirming their right to consent honors their autonomy and builds trust.
C. Questioning the client’s decision undermines their beliefs and autonomy.
D. Reassuring the client about blood loss dismisses their valid concerns about transfusion refusal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A: Covering the bowel with sterile gauze moistened with saline protects the exposed tissue and prevents it from drying out.
B: A low-Fowler's position with knees flexed reduces strain on the abdomen and minimizes further protrusion.
C: A side-lying position does not relieve strain on the abdominal incision as effectively as a low-Fowler’s position.
D: Retrieving the crash cart is unnecessary unless there is evidence of impending cardiopulmonary arrest.
E: Calling for assistance is essential to notify the surgical or medical team promptly.
F: Measuring inspiratory volume is irrelevant in this scenario and delays appropriate intervention.
Correct Answer is C
Explanation
A. Administering analgesics is not a priority in managing low oxygen saturation.
B. Administering oxygen is important but should follow positioning to improve oxygenation.
C. Raising the head of the bed improves lung expansion and is the priority intervention.
D. Coughing and deep breathing can follow after oxygenation is stabilized.
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