A nurse is caring for a client on the medical-surgical unit.

The client has been taking warfarin at home and her laboratory values reveal her INR is 3.5. The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her.

Which of the following actions should the nurse take?

Choice A rationale: Yellow sclera indicates jaundice, a clinical sign of elevated bilirubin caused by hepatocellular damage. Isoniazid and rifampin are both hepatotoxic drugs commonly used in tuberculosis treatment. When the liver is compromised, bilirubin accumulates and is deposited in the sclera and skin. This clinical presentation requires immediate provider notification, as it may indicate early liver failure or the need to discontinue hepatotoxic medications to prevent worsening hepatic injury.

Choice B rationale: The AST level has increased from 35 to 36 units/L, reaching the upper limit of normal. Normal AST is 0–35 units/L. Although this is a slight increase, in the context of tuberculosis treatment with known hepatotoxic medications like isoniazid and rifampin, even a small upward trend can be an early warning of hepatic injury. Hepatotoxicity can progress rapidly, so any increase warrants provider notification for monitoring or possible medication adjustment.

Choice C rationale: The 3.2 kg (7 lb) weight loss is a classic symptom of tuberculosis due to increased metabolic demand and decreased appetite from systemic inflammation. However, this weight loss is already known and part of the client's initial presentation, not a new or worsening symptom. It does not require immediate provider notification unless the weight loss continues to progress or is accompanied by other signs of deterioration such as hypotension or electrolyte imbalance.

Choice D rationale: The Mantoux test showed a 12 mm induration, which is considered positive in individuals with risk factors like recent travel or suggestive radiographic findings. However, a positive Mantoux alone is not urgent, especially when TB has already been suspected and treatment has been initiated. It confirms exposure but does not require immediate provider notification unless being used for new diagnosis initiation. The result is consistent with the working diagnosis of tuberculosis.

Choice E rationale: ALT increased from 36 to 38 SI/L, exceeding the upper limit of normal (4–36 SI/L). ALT is a liver-specific enzyme, and its elevation strongly suggests hepatocellular injury. Both isoniazid and rifampin are known to elevate ALT levels. Even a minor elevation in ALT in this context may be the beginning of drug-induced hepatitis, which can progress without early intervention. Prompt reporting is needed to assess medication risks and protect liver function.

Choice F rationale: Reddish-orange urine is a well-documented, harmless side effect of rifampin. This medication binds to chromophores and imparts a discoloration to urine, sweat, tears, and saliva. It is not a sign of renal dysfunction or drug toxicity. Patient education on this harmless but expected effect is important, but it does not require provider notification. Misinterpretation may cause alarm, but the discoloration is entirely benign and anticipated during rifampin therapy.

Choice A rationale: Decreased lung sounds following thoracentesis may indicate a pneumothorax, especially when combined with other signs such as shortness of breath or changes in respiratory effort. Pneumothorax is a known complication post-thoracentesis due to lung collapse or puncture. Immediate assessment and chest x-ray are needed to rule this out. Lung sounds should improve after fluid removal, not diminish, making this a critical finding requiring follow-up.

Choice B rationale: A dry puncture site is an expected and normal finding following thoracentesis. It indicates that there is no ongoing fluid or air leakage from the site. The integrity of the dressing and absence of drainage suggest proper wound healing and that the procedure was done correctly. This finding does not require immediate follow-up and is actually a sign of stable post-procedural status.

Choice C rationale: Subcutaneous emphysema indicates air has leaked into the subcutaneous tissue, often from the pleural space due to lung injury or puncture. It presents as swelling and a crackling sensation under the skin and is a potential sign of pneumothorax. It must be followed up immediately because it may progress or indicate a more serious underlying pulmonary complication that requires prompt evaluation and potential intervention.

Choice D rationale: An oxygen saturation of 95% is generally acceptable in most patients, but in this specific context—post-thoracentesis in a patient with a history of lung cancer and repeated pleural effusions—this value could mask early respiratory compromise. The patient initially had a saturation of 91%, and although this improved, the presence of ongoing respiratory symptoms like labored breathing or other abnormal signs warrants close monitoring and possibly further evaluation to ensure respiratory stability.