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
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of autonomy (self-determination) and is legally protected.
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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.
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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.
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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