A nurse is caring for a client who refuses a blood transfusion. Which of the following actions should the nurse take?

Rationale: A. While risk management may become involved in some complex legal or ethical cases, the first and most immediate nursing action is to document the client’s informed refusal and ensure the healthcare team is aware. Escalation to risk management is not the priority initial step. B. Clients have the legal and ethical right to refuse treatment, including blood transfusions, as long as they are competent and informed. Forcing or implying that the procedure is mandatory violates the principles of autonomy and informed consent. C. When a client refuses a prescribed treatment, the nurse’s priority is to document the refusal accurately and objectively in the medical record. This documentation should include what was refused, the information provided to the client about risks and benefits, the client’s stated understanding, and any notifications made to the provider. This ensures legal protection for the client and healthcare team. D. While discussing alternatives may be appropriate as part of ongoing care planning, it does not take priority over respecting autonomy and documenting the refusal. Alternative therapies should be explored in collaboration with the provider after refusal is documented and acknowledged.