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?
Tell the client if she leaves without a written prescription for discharge, her insurance will not pay for the facility visit.
Tell the client she will not be permitted to leave the facility until she has signed the against medical advice (AMA) form.
Ask the security department to guard the room to the client's door.
Explain the risk the client faces if she leaves the facility.
The Correct Answer is D
Choice A rationale
Discussing insurance coverage is beyond the nurse's scope of practice and does not address the immediate safety concern related to the elevated INR. The nurse's primary responsibility is patient safety and education regarding potential health risks, not financial implications. The client's autonomy in making healthcare decisions is paramount.
Choice B rationale
A client cannot be legally detained in a healthcare facility against their will, assuming they are of sound mind. Requiring a signed Against Medical Advice (AMA) form is a documentation process, not a prerequisite for discharge. Detaining a competent client constitutes false imprisonment, violating their civil liberties.
Choice C rationale
Asking security to guard the room is a restrictive action that infringes upon the client's autonomy and right to leave. This approach is coercive and may escalate the situation, potentially leading to a legal and ethical dilemma. It does not prioritize patient education or safety through explanation.
Choice D rationale
Explaining the risks associated with leaving against medical advice, especially with an elevated INR, is crucial for informed decision-making. An INR of 3.5 indicates increased bleeding risk (normal range 0.8-1.2 or 2.0-3.0 for therapeutic anticoagulation). Providing this scientific information allows the client to understand potential adverse physiological events.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Aspiration, while a serious respiratory event, leads to direct lung injury and inflammation, potentially contributing to ARDS. However, it is not the most common cause globally, as the systemic inflammatory response of sepsis often precipitates more widespread and severe lung damage.
Choice B rationale
Sepsis is widely recognized as the most common cause of acute respiratory distress syndrome (ARDS). The systemic inflammatory response initiated by sepsis leads to widespread endothelial damage and increased capillary permeability in the lungs, resulting in non-cardiogenic pulmonary edema and severe hypoxemia.
Choice C rationale
Motor vehicle accident trauma can lead to ARDS, particularly if there is direct chest injury or systemic inflammatory response due to widespread tissue damage. However, compared to the incidence of sepsis as a precipitating factor, trauma accounts for a smaller percentage of ARDS cases.
Choice D rationale
Pneumonia, especially severe cases, can directly cause lung inflammation and injury, potentially progressing to ARDS. While a significant cause, pneumonia itself can sometimes be a complication of underlying conditions or a localized insult, whereas sepsis triggers a more profound systemic inflammatory cascade.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale: Administering antibiotics is not appropriate for influenza B because it is caused by a virus, not bacteria. Antibiotics target bacterial infections and are ineffective against viral pathogens. Unnecessary antibiotic use can lead to antibiotic resistance and adverse effects. Treatment for influenza is primarily supportive care and antiviral medications if indicated, not antibiotics.
Choice B rationale: Airborne precautions are used for infections spread via small airborne particles, such as tuberculosis or measles. Influenza B spreads mainly through respiratory droplets and contact, not through airborne transmission. Therefore, droplet precautions are appropriate rather than airborne precautions for influenza B, making airborne precautions unnecessary.
Choice C rationale: Wearing a mask is essential when caring for a client with influenza B because the virus transmits through respiratory droplets released during coughing, sneezing, or talking. Masks help protect healthcare workers from inhaling infectious droplets, reducing transmission risk. Surgical masks are appropriate for droplet precautions, ensuring safety during close contact.
Choice D rationale: Placing the client in a private room helps prevent the spread of influenza B to other patients and staff. Isolation limits exposure and allows implementation of droplet precautions effectively. This is a standard infection control measure in healthcare settings for clients with contagious respiratory infections.
Choice E rationale: Encouraging increased fluid intake is important for clients with influenza to prevent dehydration due to fever, sweating, and poor oral intake. Adequate hydration supports immune function, helps loosen mucus, and maintains overall physiological stability. Fluids also help reduce symptoms such as sore throat and fatigue.
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