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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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Sepsis, particularly from gramnegative bacterial infections, is the most common cause of ARDS. The systemic inflammatory response associated with sepsis triggers widespread endothelial damage, increased capillary permeability, and fluid leakage into the alveoli, leading to noncardiogenic pulmonary edema and severe hypoxemia.
B. Aspiration of gastric contents, especially in critically ill or unconscious patients, is a significant risk factor for ARDS. However, while aspiration can lead to chemical pneumonitis and subsequent ARDS, it is not the most common cause compared to sepsis.
C. Motor vehicle accident trauma. Trauma, particularly from chest injuries, fractures, or major surgeries, can lead to ARDS secondary to systemic inflammation and fat embolism. However, direct lung injury from trauma is less frequent than sepsisinduced ARDS.
D. Pneumonia. Severe pneumonia, especially when caused by virulent pathogens like COVID19, influenza, or bacterial infections, can lead to localized lung damage and ARDS. Although pneumonia is a major cause, sepsis remains the leading trigger of ARDS due to its systemic inflammatory effects.

A. The client eats red meat daily. B. The client has had gastric bypass surgery. C. The client has had treatment for gastrointestinal cancer. D. The client eats mostly prepackaged. processed foods. E. The client has ulcerative colitis.

Correct Answer is ["B","C","D","E"]

Explanation

A. The client eats red meat daily. Red meat is a rich source of heme iron, which is highly bioavailable and helps prevent iron deficiency anemia. Regular consumption of red meat typically reduces, rather than increases, the risk of iron deficiency.
B. The client has had gastric bypass surgery. Gastric bypass surgery alters the digestive tract, reducing stomach acid production and the absorption of iron in the duodenum and proximal jejunum, which are primary sites for iron uptake. This increases the risk of iron deficiency anemia.
C. The client has had treatment for gastrointestinal cancer. Cancer treatments, particularly chemotherapy, radiation, and surgical resections, can impair nutrient absorption and lead to chronic gastrointestinal bleeding, increasing the risk of iron deficiency anemia.
D. The client eats mostly prepackaged, processed foods. Processed foods are often low in ironrich sources such as lean meats, leafy greens, and legumes. A diet lacking in ironcontaining whole foods can contribute to iron deficiency over time.
E. The client has ulcerative colitis. Chronic inflammation, intestinal bleeding, and malabsorption associated with ulcerative colitis contribute to iron deficiency anemia. Frequent episodes of bloody diarrhea can lead to significant iron loss, further exacerbating anemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS). The nurse should identify that which of the following conditions is the most common cause of ARDS?

Correct Answer is A

Explanation

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as possible risk factors for iron deficiency anemia? (Select All that Apply.)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is caring for a client. Exhibits Based on the information in the EHR, which of the following actions should the nurse take? Select all that apply.

A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

A nurse is assessing a client who has a possible abdominal aortic aneurysm (AAA). Which of the following is an early manifestation of an AAA?

A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?

A nurse is providing teaching to a client who has atrial fibrillation and reports dizziness and palpitations. Which of the following should the nurse understand is the cause of these manifestations?