A nurse is planning care for a client who has an absolute neutrophil count (ANC) less than 1,000/mm3. Which of the following interventions should the nurse include in the plan?

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.

A. Eyelets are not visible. The eyelets of the chest tube should not be visible if the tube is correctly positioned inside the pleural space. Visible eyelets indicate tube dislodgement, which is a concern, but the provider does not need to be notified if the chest tube is secure and functioning properly.
B. Bubbling of the water in the water seal chamber with exhalation. This is an expected finding in a client with a pneumothorax, as air escapes from the pleural space. Intermittent bubbling with exhalation, coughing, or sneezing indicates that the pneumothorax is resolving. Continuous bubbling, however, could indicate an air leak and would require further assessment.
C. Crepitus in the area above and surrounding the insertion site. Crepitus, or subcutaneous emphysema, occurs when air leaks into the subcutaneous tissue. While it can be a sign of a small air leak, it is not always an emergency. The nurse should monitor for increasing crepitus and signs of worsening respiratory distress, but immediate provider notification is not always required.
D. Movement of the trachea toward the unaffected side. Tracheal deviation is a sign of tension pneumothorax, a lifethreatening emergency that requires immediate intervention. It occurs when air continues to accumulate in the pleural space without an exit, leading to increasing intrathoracic pressure. This shifts the mediastinum and trachea away from the affected lung, compressing the heart and great vessels, which can rapidly lead to cardiac arrest. The provider must be notified immediately to prevent further deterioration.