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 C
Explanation
Choice A rationale:
Irrigating the tubing with sterile normal saline solution is not a routine part of closed-wound drainage system care.
It's usually only done if there's evidence of a blockage or infection, and only under the direction of a healthcare provider. Unnecessary irrigation could introduce bacteria into the system and increase the risk of infection.
It could also disrupt the delicate balance of fluids in the wound and delay healing.
Choice B rationale:
Replacing the drainage plug after releasing hand pressure on the device is not correct. The drainage plug should actually be replaced before releasing hand pressure.
This is to prevent air from entering the system, which could disrupt the vacuum and impair drainage.
Choice D rationale:
Emptying the reservoir once per day is not frequent enough.
The reservoir should be emptied whenever it becomes full, which could be more often than once a day, depending on the amount of drainage.
Allowing the reservoir to become too full could put pressure on the wound and impede healing.
Choice C rationale:
Fully re-collapsing the reservoir after emptying it is essential to maintain the vacuum that promotes drainage. If the reservoir is not fully re-collapsed, the vacuum will be lost, and drainage will slow or stop.
This could lead to fluid accumulation in the wound, which could increase the risk of infection and delay healing.
Correct Answer is A
Explanation
Choice A rationale:
Respects patient autonomy: This response directly addresses the patient's preference and demonstrates respect for their right to make decisions about their own care. It empowers the patient by offering a solution that aligns with their stated wishes.
Promotes patient comfort: By accommodating the patient's preference, the nurse can help to create a more comfortable and trusting environment, which can lead to better patient outcomes.
Protects patient privacy: Personal hygiene care often involves exposure of sensitive body parts and can be a source of embarrassment or anxiety for some patients. Ensuring that the patient is comfortable with the gender of the caregiver helps to protect their privacy and dignity.
Demonstrates cultural sensitivity: While not explicitly stated in the question, it's possible that the patient's preference is rooted in cultural or religious beliefs. Being sensitive to these factors is essential for providing culturally competent care.
Provides a practical solution: This response offers a concrete solution that can be easily implemented, ensuring that the patient's needs are met in a timely and efficient manner.
Choice B rationale:
May be perceived as intrusive: Asking the patient to explain their reasoning could make them feel uncomfortable or defensive. It's important to respect the patient's right to privacy and not pressure them to disclose personal information.
Could delay care: While understanding the patient's reasons may be helpful in some cases, it's not essential for providing appropriate care. Delaying care to gather this information could potentially compromise the patient's well-being.
Choice C rationale:
Dismisses patient's concerns: This response fails to acknowledge the patient's preference and could make them feel unheard or disrespected. It's important to validate the patient's feelings and concerns, even if you don't fully understand them.
May not address underlying issues: The patient's preference may be based on factors that are not related to the AP's competence or experience. Simply stating the AP's qualifications is unlikely to resolve the patient's concerns.
Choice D rationale:
Defers responsibility: While informing the charge nurse may be necessary for logistical reasons, it's important for the nurse to take ownership of the situation and address the patient's concerns directly. Deferring to another staff member could make the patient feel like their concerns are not being taken seriously.
May delay care: Involving additional staff members could potentially delay the patient's care. It's more efficient to address the patient's preference directly, if possible.
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