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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","E"]

Explanation

A. Yellow sclera: This may indicate hepatotoxicity, a serious adverse effect of isoniazid and rifampin. The provider should be notified immediately to assess liver function and adjust medications if necessary.
B. Increasing AST level: The AST increased from 35 to 36 units/L, which is within the normal range but may suggest early signs of liver dysfunction, especially in combination with other findings like jaundice.
C. Weight loss: While weight loss is a symptom of tuberculosis (TB), the client reported a 3.2 kg (7 lb) loss before admission. Since this is an expected finding with TB, it does not necessarily require immediate provider notification unless it continues despite treatment.
D. Mantoux test result: A 12 mm induration is considered positive in highrisk populations but does not confirm active TB. Given that the client already has a chest Xray showing caseation, a positive skin test is not the most critical finding to report.
E. Increasing ALT level: The ALT increased from 36 to 38 SI/L, which is a slight rise but, along with the AST increase and jaundice, suggests possible liver dysfunction due to TB medications.
F. Reddishorange urine color: This is a normal side effect of rifampin and does not indicate harm. It does not require provider notification.

A. Chest xray B. Echocardiogram C. Computed tomography (CT) scan D. Electrocardiogram (ECG)

Correct Answer is B

Explanation

A. Chest xray. A chest xray may show an enlarged cardiac silhouette ("water bottle heart") due to the accumulation of pericardial fluid, but it is not the most immediate or definitive diagnostic tool for cardiac tamponade.
B. Echocardiogram. An echocardiogram is the firstline diagnostic test for suspected cardiac tamponade. It provides realtime imaging of the heart, allowing visualization of pericardial effusion, right ventricular collapse during diastole, and impaired cardiac filling, which are hallmark signs of tamponade. It is noninvasive, rapid, and highly sensitive, making it the preferred initial test.
C. Computed tomography (CT) scan. A CT scan can detect pericardial effusion, but it is not the first choice due to longer imaging time and lower practicality in an emergent setting. It is often used when echocardiography is inconclusive or when other mediastinal pathology is suspected.
D. Electrocardiogram (ECG). An ECG in tamponade may show low voltage QRS complexes, electrical alternans, or nonspecific ST changes, but these findings are not definitive. ECG cannot directly visualize pericardial fluid or hemodynamic compromise, making it less useful than echocardiography for confirming the diagnosis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medicalsurgical unit is caring for a newly admitted client with a diagnosis of R/O tuberculosis. Exhibits Which of the following findings should the nurse report to the provider?

Correct Answer is ["A","B","E"]

Explanation

A nurse is planning care for a client who has suspected cardiac tamponade. Which of the following diagnostic tests should the nurse anticipate the provider to order first?

Correct Answer is B

Explanation

A nurse is caring for a 75.year.old male client who is experiencing difficulty breathing and shortness of breath. Exhibits The nurse is caring for the client following a thoracentesis. Select the 3 findings that require immediate follow.up.

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.)

A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?