A nurse is assessing a patient following the removal of the patient’s endotracheal tube. Which finding should the nurse report to the provider?

Rationale for Choice A:

Refer Questions to the Nursing Supervisor:

While it's essential to involve the nursing supervisor in situations that require their expertise or authority, it's not always necessary for basic inquiries about a patient's presence on the unit.

Disadvantages of referring calls to the nursing supervisor in this scenario:

It could delay the dissemination of essential information to concerned colleagues.

It could increase the workload of the nursing supervisor, potentially diverting their attention from more critical tasks. It could create a perception of a lack of transparency or openness among staff members.

Rationale for Choice B:

Transfer calls directly to the patient’s room:

Transferring calls directly to a patient's room without their consent breaches their privacy and confidentiality. It could also place undue stress on the patient, especially if they are not prepared to receive calls or discuss their health status.

Disadvantages of transferring calls directly to the patient’s room:

It violates the patient's right to privacy and confidentiality. It could disrupt the patient's rest and recovery.

It could place the patient in an uncomfortable position of having to answer questions about their health when they may not feel ready to do so.

Rationale for Choice C:

Acknowledge that the person is a patient on the unit, but give no specific details about the patient’s condition:

This approach strikes a balance between protecting the patient's privacy and providing necessary information to concerned colleagues. It verifies the patient's presence on the unit without disclosing any sensitive details about their health, thus adhering to ethical and legal guidelines.

Advantages of acknowledging the patient’s presence without providing details:

Respects the patient's right to privacy and confidentiality. Aligns with ethical and legal principles of healthcare.

Provides basic information to concerned colleagues without compromising patient information. Helps to establish trust and transparency among staff members.

Rationale for Choice D:

Contact the patient’s provider:

Contacting the patient's provider for every inquiry about the patient's presence is not practical or efficient. It could overburden the provider and delay the relay of information to concerned colleagues.

Choice A rationale:

Notifying the facility's security department may be necessary in some cases, but it should not be the nurse's first action. This could escalate the situation and make the patient feel threatened or coerced. It's important to first attempt to de-escalate the situation and understand the patient's reasons for wanting to leave. Involving security prematurely could damage the nurse- patient relationship and make it more difficult to provide care in the future.

Security should be involved if the patient is a danger to themselves or others, or if they are attempting to leave in a way that could cause harm. However, in most cases, it is best to try to resolve the situation through communication and understanding.

Choice B rationale:

Calling the patient's family may be helpful in some cases, but it is not always necessary or appropriate. The nurse should first assess the patient's decision-making capacity and their understanding of the risks of leaving against medical advice. If the patient is capable of making their own decisions, the nurse should respect their autonomy and not involve family members without their consent.

Involving family members without the patient's consent could breach confidentiality and erode trust. It's important to balance the patient's right to privacy with the potential benefits of involving family members.

Choice C rationale:

Insisting that the patient exit the hospital via a wheelchair is not necessary in most cases. If the patient is able to walk and does not pose a safety risk, they should be allowed to leave on their own terms. Requiring a wheelchair could be seen as patronizing or controlling, and it could further upset the patient.

The use of a wheelchair should be based on the patient's individual needs and preferences, not on a blanket policy.

Choice D rationale:

Making sure the patient understands that they are leaving against medical advice is the most important action the nurse can take. This ensures that the patient is aware of the potential risks of leaving the hospital, and it protects the nurse from liability. The nurse should document the patient's decision in the medical record and have the patient sign an Against Medical Advice (AMA) form.

By ensuring informed consent, the nurse respects the patient's autonomy while also fulfilling their professional obligations.