A client has refused a prescribed injection of subcutaneous heparin. Which initial action should the nurse take?
A client has refused a prescribed injection of subcutaneous heparin. Which initial action should the nurse take?
A. Document the refusal
[17%]
B. Notify the primary healthcare provider (PHCP)
[13%]
C. Review the client's most recent platelet count
[9%]
D. Inquire with the client about the refusal
[61%]
Statistics
Subject/Lesson
Subject
Leadership & Management
Lesson
Ethical/Legal
Client Need
Test Plan
Pharmacological and Parenteral Therapies
Related Topic
Medication Administration
Item Type
Item Type
Knowledge/Comprehension
Explanation
Choice D is correct. The appropriate and initial nursing action is to inquire with the client about their rationale for refusing the medication. Assessment is the initial part of the nursing process, and discussing the refusal with the client is a step the nurse should execute.
Choices A, B, and C are incorrect. Documenting the refusal should not prioritize over inquiring with the client about their reasoning for refusing the prescription. If the client still refuses after the nurse has thoroughly educated the client on the medication and its purpose. The nurse should contact the PHCP and document the refusal accordingly. Reviewing the client's platelet count is inappropriate as it is irrelevant to the refusal. This action should have been completed before obtaining the medication.
Related Videos
4 Key Topics
Autonomy
15.10 Ethical Principles in Healthcare
Nursing Process (ADPIE)
15.6 Prioritization Part 2
Additional Info
As a competent adult, it is the client's right to refuse treatment for any reason, even when refusal might compromise the client's health or death. The nurse should inquire about a refusal and clear up any questions the client may have regarding the medication or treatment. The nurse should also educate the client on the purpose of the prescription and treatment. If that is ineffective, the nurse should contact the PHCP and relay the refusal. All actions, including the client's statements regarding the refusal, should be documented.
