beacons.ai/nursingexam
A nurse is caring for a client who refuses a blood transfusion.
Which of the following actions should the nurse take?"
This question tests the nurse's understanding of a fundamental
ethical and legal principle in healthcare: patient autonomy and
the right to refuse treatment.
Page 2: The Correct Answer and Its Justification
Correct Answer:
Document the clients’ refusal in the medical record.
Detailed Justification:
Legal and Ethical Imperative: A competent adult has the
unequivocal right to refuse any medical treatment, even if the
,refusal may lead to serious injury or
beacons.ai/nursingexam
1. WUIWEUI3QEdeath. This right is grounded in the ethical
principle of autonomy (self-determination) and is legally
protected.
beacons.ai/nursingexam
2.
3.
beacons.ai/nursingexam
4. The Role of Documentation: The nurse's primary
responsibility in this situation is to ensure the client's
decision is clearly, accurately, and promptly communicated
within the healthcare team. Documentation in the medical
record serves this critical purpose. It:
o Creates a legal record of the client's informed
decision.
o xvnvnGF
o Protects the client by ensuring their wishes are
known and (theoretically) followed.
o Protects the nurse and the healthcare facility from
claims of battery (unauthorized
touching/treatment) or negligence.
Informs all caregivers of the current plan of care, which is now to
provide treatment without the transfusion.
beacons.ai/nursingexam
o
Page 3: Analysis of the Incorrect Options
, Understanding why the other options are wrong is crucial for
developing sound clinical judgment. ATI RN Comprehensive
Predictor 2023–2025 Exit Exam (NGN Format) | 180 Solved and
Verified Questions with 100% Correct Answers – Real 2025
Version
beacons.ai/nursingexam
WQAS8UIWEAjkmNotify risk management about the
clients’ refusal.
o Why it's Incorrect: While risk management may
eventually be involved, especially if there is a
dispute or an adverse outcome, it is not the
nurse's first or primary action. The immediate
priority is to respect the client's choice and
document it. Notifying risk management first can
be perceived as prioritizing institutional liability
over patient autonomy.
Inform the client that the transfusion is mandatory.
o Why it's Incorrect: This is a direct violation of the
client's legal and ethical rights. Except in very
specific, legally-defined circumstances (e.g., a court
order for a public health threat, or treatment under
the Mental Health Act for a mentally incompetent
person), no treatment is "mandatory" for a
competent adult. This action would be considered
coercive and unethical.
Suggest that the client explore alternative therapies.
beacons.ai/nursingexam
2QWUIDKWi
Why it's Incorrect: While shared decision-making and exploring
options are part of nursing care, this is not the immediate action.
A nurse is caring for a client who refuses a blood transfusion.
Which of the following actions should the nurse take?"
This question tests the nurse's understanding of a fundamental
ethical and legal principle in healthcare: patient autonomy and
the right to refuse treatment.
Page 2: The Correct Answer and Its Justification
Correct Answer:
Document the clients’ refusal in the medical record.
Detailed Justification:
Legal and Ethical Imperative: A competent adult has the
unequivocal right to refuse any medical treatment, even if the
,refusal may lead to serious injury or
beacons.ai/nursingexam
1. WUIWEUI3QEdeath. This right is grounded in the ethical
principle of autonomy (self-determination) and is legally
protected.
beacons.ai/nursingexam
2.
3.
beacons.ai/nursingexam
4. The Role of Documentation: The nurse's primary
responsibility in this situation is to ensure the client's
decision is clearly, accurately, and promptly communicated
within the healthcare team. Documentation in the medical
record serves this critical purpose. It:
o Creates a legal record of the client's informed
decision.
o xvnvnGF
o Protects the client by ensuring their wishes are
known and (theoretically) followed.
o Protects the nurse and the healthcare facility from
claims of battery (unauthorized
touching/treatment) or negligence.
Informs all caregivers of the current plan of care, which is now to
provide treatment without the transfusion.
beacons.ai/nursingexam
o
Page 3: Analysis of the Incorrect Options
, Understanding why the other options are wrong is crucial for
developing sound clinical judgment. ATI RN Comprehensive
Predictor 2023–2025 Exit Exam (NGN Format) | 180 Solved and
Verified Questions with 100% Correct Answers – Real 2025
Version
beacons.ai/nursingexam
WQAS8UIWEAjkmNotify risk management about the
clients’ refusal.
o Why it's Incorrect: While risk management may
eventually be involved, especially if there is a
dispute or an adverse outcome, it is not the
nurse's first or primary action. The immediate
priority is to respect the client's choice and
document it. Notifying risk management first can
be perceived as prioritizing institutional liability
over patient autonomy.
Inform the client that the transfusion is mandatory.
o Why it's Incorrect: This is a direct violation of the
client's legal and ethical rights. Except in very
specific, legally-defined circumstances (e.g., a court
order for a public health threat, or treatment under
the Mental Health Act for a mentally incompetent
person), no treatment is "mandatory" for a
competent adult. This action would be considered
coercive and unethical.
Suggest that the client explore alternative therapies.
beacons.ai/nursingexam
2QWUIDKWi
Why it's Incorrect: While shared decision-making and exploring
options are part of nursing care, this is not the immediate action.
