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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Reviewing all current medications and supplements allows the healthcare team to identify potential drug interactions and adjust treatment.

B. While a medication schedule is helpful, it does not address the risk of interactions during pre-surgical planning.

C. Instructing the client to avoid OTC medications is overly broad and may lead to unnecessary medication omission.

D. Filling prescriptions locally does not address the risk of interactions directly.

A. Assess the surgical dressing, noting presence and character of drainage. B. Assess urinary output and presence of bladder distention. C. Assess blood pressure and the estimated blood loss during surgery. D. Assess for airway patency and quality of respirations.

Correct Answer is D

Explanation

A. Checking the surgical dressing is important but not as urgent as ensuring respiratory function.

B. Assessing urinary output is necessary but secondary to airway patency.

C. Monitoring blood pressure and blood loss is important but less critical than respiratory status.

D. Airway patency is the highest priority in the immediate postoperative period to prevent respiratory failure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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