A nurse is caring for a client who is requesting to leave the facility against medical advice (AMA). The client states, "I am ready to go immediately." Which of the following actions should the nurse take first?

Teach the client about the potential health risks of leaving early.

Ask the client to sign a document stating they are leaving AMA.

Document the client's statement in direct quotes in the medical record.

Complete an incident report detailing the client scenario.

Answer and Explanation

The Correct Answer is A

A. Teach the client about the potential health risks of leaving early: The first action the nurse should take is to inform the client about the potential health risks associated with leaving the facility against medical advice. Providing this information ensures that the client is fully informed about the consequences of their decision, which is essential for promoting their safety and well-being.

B. Ask the client to sign a document stating they are leaving AMA: While obtaining a signed document is necessary, it should occur after the client has been informed about the risks involved in leaving. The nurse should first ensure the client understands the implications of their decision.

C. Document the client's statement in direct quotes in the medical record: Documentation is important but should not be the first action taken. The nurse must first address the client’s immediate request and provide information regarding potential health risks before focusing on documentation.

D. Complete an incident report detailing the client scenario: Completing an incident report may be necessary later, but the priority should be to address the client’s safety and ensure they are making an informed decision about leaving the facility. The nurse should first engage with the client regarding their choice and the associated risks.

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Correct Answer is A

Explanation

A. "I have a severe allergy to amoxicillin." A severe allergy to amoxicillin suggests a potential cross-reactivity with ceftriaxone, as both belong to the beta-lactam antibiotic class. While cross-reactivity between penicillins and cephalosporins is lower with third-generation cephalosporins like ceftriaxone, a history of severe allergic reactions, such as anaphylaxis, warrants consultation with the provider before administration.

B. "I get sick when I take diuretics." Adverse effects from diuretics do not typically indicate a contraindication to ceftriaxone. While diuretics like furosemide can interact with aminoglycosides to increase nephrotoxicity, ceftriaxone does not share this risk. Monitoring for individual tolerances is important, but this statement does not require holding the medication.

C. "I have a history of hearing problems." Ceftriaxone is not associated with ototoxicity, unlike aminoglycosides or vancomycin. A history of hearing problems does not necessitate withholding the medication, though the nurse should monitor for any new or worsening symptoms if concurrent ototoxic medications are prescribed.

D. "I take prednisone for my asthma." Corticosteroid use does not directly contraindicate ceftriaxone administration. While prolonged corticosteroid therapy may increase the risk of infections or mask symptoms of an allergic reaction, it does not warrant holding the antibiotic. The nurse should continue routine monitoring but can safely proceed with administration.

A. Hospital ethics committee B. Quality improvement committee C. Chaplain D. Director of nursing

Correct Answer is A

Explanation

A. Hospital ethics committee: The nurse should consult the hospital ethics committee for guidance in resolving ethical conflicts related to client care. This committee is specifically designed to address ethical dilemmas and provide support for decision-making, ensuring that care aligns with ethical principles and the client's values.

B. Quality improvement committee: While the quality improvement committee focuses on enhancing care quality and patient safety, it is not primarily concerned with resolving ethical dilemmas. This committee may address systemic issues, but it does not specialize in ethical conflicts regarding individual client care.

C. Chaplain: While a chaplain can provide spiritual support and guidance, they may not be equipped to address the ethical aspects of the client's care. Consulting a chaplain could be helpful for emotional or spiritual concerns, but the ethics committee is more appropriate for resolving ethical dilemmas.

D. Director of nursing: The director of nursing may provide support and resources, but they may not have specialized training in ethics. Referring to the hospital ethics committee is more appropriate for addressing specific ethical conflicts in client care.

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A nurse is caring for a client who is requesting to leave the facility against medical advice (AMA). The client states, "I am ready to go immediately." Which of the following actions should the nurse take first?

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