A nurse is caring for a client on the medicalsurgical 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 she will not be permitted to leave the facility until she has signed the against medical advice (AMA) form.
Explain the risk the client faces if she leaves the facility.
Ask the security department to guard the room to the client's door.
Tell the client if she leaves without a written prescription for discharge, her insurance will not pay for the facility visit.
The Correct Answer is B
A. Tell the client she will not be permitted to leave the facility until she has signed the against medical advice (AMA) form. Clients have the right to refuse treatment and leave the hospital, even against medical advice. While signing an AMA form is encouraged, the client cannot be forced to stay or sign the form before leaving.
B. Explain the risk the client faces if she leaves the facility. The nurse’s priority is to educate the client about the potential dangers of leaving, including the increased risk of bleeding due to the elevated INR level. Providing information allows the client to make an informed decision about their care.
C. Ask the security department to guard the room to the client's door. Using security to prevent a client from leaving would be a violation of their autonomy and rights. Security should only be involved if the client is a danger to themselves or others, which is not indicated in this case.
D. Tell the client if she leaves without a written prescription for discharge, her insurance will not pay for the facility visit. This is inappropriate and may not be accurate. A client’s decision to leave AMA does not necessarily impact insurance coverage, and this approach would be coercive rather than focusing on providing informed care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Analgesic. While aspirin has painrelieving (analgesic) properties, it is not prescribed at 325 mg for postMI clients primarily for pain relief. Instead, its role in preventing platelet aggregation is the key factor in reducing future cardiovascular events.
B. Antipyretic. Aspirin can reduce fever (antipyretic effect) by inhibiting prostaglandin synthesis in the hypothalamus. However, postMI clients are not prescribed aspirin for fever reduction but rather for its cardiovascular protective effects.
C. Antiinflammatory. Aspirin is a nonsteroidal antiinflammatory drug (NSAID) and can reduce inflammation. However, at low doses (81–325 mg), its primary function is not antiinflammatory but rather to reduce clot formation and prevent arterial blockage.
D. Antiplatelet aggregate. This is correct. Aspirin inhibits platelet aggregation by blocking cyclooxygenase1 (COX1), which prevents thromboxane A₂ production, thereby reducing the risk of clot formation. This action is critical for preventing recurrent myocardial infarction or stroke in highrisk clients.
Correct Answer is A
Explanation
A. Clear breath sounds. This is the best indicator that suctioning was effective. Before suctioning, the child may have adventitious lung sounds (e.g., coarse crackles, rhonchi) due to airway secretions. After proper suctioning, the nurse should auscultate the lungs for improved air movement and the absence of abnormal sounds, indicating successful removal of mucus and restoration of a patent airway.
B. Increased respiratory rate. An increased respiratory rate after suctioning may indicate distress, hypoxia, or incomplete secretion removal, suggesting that suctioning was ineffective or that the procedure caused airway irritation. Ideally, suctioning should result in a stable or improved respiratory rate, not an increase.
C. Brisk capillary refill. Capillary refill time (CRT) is a general indicator of peripheral perfusion and circulatory status, not respiratory function. While poor CRT may indicate hypoxia or shock, it is not a primary measure of suctioning effectiveness.
D. Stable oxygen saturation. While maintaining stable oxygen saturation is important, an improvement in SpO₂ levels after suctioning would be a better indicator of effectiveness. However, SpO₂ alone does not confirm airway clearance, as other factors (e.g., oxygen delivery settings) can influence readings. Auscultation of clear breath sounds remains the most definitive assessment of effective secretion removal.
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