A nurse is caring for a patient on a medical-surgical unit who is attempting to leave the facility. What action should the nurse take?
Notify the facility’s security department
Call the patient’s family
Insist that the patient exit the hospital via a wheelchair
Make sure the patient understands that they are leaving against medical advice
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Hypovolemic shock is a life-threatening condition that occurs when the body loses a significant amount of blood or fluids, leading to a decrease in circulating blood volume. This can result in inadequate perfusion of organs and tissues, which can cause damage and even death if not treated promptly.
In this case, the athlete's symptoms and vital signs are consistent with hypovolemic shock. The athlete has been practicing twice a day in the heat, which can lead to significant fluid loss through sweating. The athlete is also dizzy, which is a common symptom of hypovolemia due to decreased blood flow to the brain. The athlete's blood pressure is low (100/2 mm Hg), pulse rate is elevated (100 beats/minute), and respiratory rate is increased (26 breaths/minute), all of which are compensatory mechanisms to try to maintain blood pressure and perfusion in the setting of hypovolemia. The athlete's skin is cool to touch
and pale in color, which is due to decreased blood flow to the skin. The athlete also does not remember the last voiding time, which may indicate decreased urine output, another sign of hypovolemia.
Key points supporting hypovolemic shock:
Significant fluid loss due to exercise in the heat Dizziness
Low blood pressure Elevated pulse rate Increased respiratory rate Cool, pale skin
Decreased urine output Additional details:
Hypovolemic shock can be caused by various factors, including:
Hemorrhage (blood loss) Severe dehydration Burns
Severe vomiting or diarrhea
Treatment for hypovolemic shock typically involves:
Intravenous fluid replacement to restore circulating blood volume Blood transfusion if the shock is due to hemorrhage
Oxygen therapy to support breathing
Medications to support blood pressure and heart function
Correct Answer is A
Explanation
Rationale for Choice A:
Ineffective airway clearance is the most immediate and life-threatening concern in the postoperative period following a radical neck dissection. This procedure involves extensive removal of lymph nodes and tissues in the neck, which can significantly disrupt normal respiratory function and airway patency. Here's a detailed explanation of the factors contributing to this risk:
Altered Respiratory Anatomy: The surgical resection of tissues and lymph nodes can directly impact the structure and function of the airway. This includes potential narrowing of the trachea, vocal cord dysfunction, and impaired laryngeal movement, all of which can hinder effective airflow.
Thick, Copious Secretions: The surgical trauma and manipulation of tissues often lead to increased production of thick, tenacious secretions in the respiratory tract. These secretions can obstruct the airway, making it difficult for the patient to clear them effectively.
Impaired Cough Reflex: The surgical dissection may disrupt the nerves involved in the cough reflex, which is a crucial mechanism for clearing secretions from the airway. This further impedes the patient's ability to maintain a patent airway.
Risk of Aspiration: Accumulation of secretions in the airway elevates the risk of aspiration, which can lead to pneumonia and other serious complications.
Potential for Edema: Postoperative swelling in the neck tissues can further compress the airway, exacerbating the risk of obstruction.
Nursing Interventions for Ineffective Airway Clearance:
Prompt recognition and management of ineffective airway clearance are essential to prevent respiratory compromise and ensure patient safety. Here are key nursing interventions that should be prioritized:
Frequent Assessment: Continuously monitor respiratory rate, effort, breath sounds, oxygen saturation, and level of consciousness for any signs of respiratory distress.
Positioning: Elevate the head of the bed to 30-45 degrees to promote lung expansion and facilitate drainage of secretions. Suctioning: Regularly suction the airway to remove secretions, using aseptic technique and proper suctioning pressure.
Deep Breathing and Coughing Exercises: Encourage and assist the patient with deep breathing and coughing exercises to mobilize secretions.
Humidification: Provide humidified oxygen or use a nebulizer to help thin secretions and make them easier to expectorate.
Chest Physiotherapy: Perform chest physiotherapy techniques, such as percussion and vibration, to loosen secretions and promote their removal.
Monitoring Fluid Balance: Maintain adequate hydration to help thin secretions, while closely monitoring fluid intake and output to prevent fluid overload.
Addressing Other Choices:
While the other choices may also be relevant concerns in the postoperative period, they do not pose the same immediate threat to life as ineffective airway clearance.
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