hard · NCLEX-RN Management of Care

Client: Robert, age 58. Setting: Cardiac Telemetry Unit. History: Post-myocardial infarction; scheduled for a coronary angiogram in 2 hours. Active Event: The client suddenly states, 'I changed my mind. I am not having this procedure, and I want to go home.' Vital Signs: BP 132/78 mm Hg, HR 82/min, RR 16/min, SpO2 97% on room air.

The client is exercising his right to refuse a scheduled cardiac catheterization. Place the following nursing actions in the correct chronological order to safely manage this informed refusal and protect the client's rights.

  1. Assess the client's understanding of the risks of refusal and confirm their decision-making capacity.
  2. Notify the primary healthcare provider and the interprofessional team of the client's refusal.
  3. Witness the client's signature on the official against medical advice or informed refusal form.
  4. Document the client's stated reasons, the specific risks explained, and the completed refusal paperwork in the health record.
  5. Update the nursing care plan to provide alternative comfort-based therapies and ensure no abandonment of care.

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