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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

NPO status (nothing by mouth) is not a relevant intervention in this situation. It would be indicated for a patient with gastrointestinal issues or prior to a procedure, but it does not address the potential consequences of rapid fluid administration.

Restricting oral intake would not reverse or mitigate the effects of fluid overload that may have already occurred.

It's important to prioritize assessment of the patient's respiratory status, as fluid overload can lead to pulmonary edema, a serious complication.

Rationale for Choice B:

Elevating the head of the bed to high Fowler's position can be helpful in easing breathing for patients with respiratory distress, but it's not the most immediate priority in this case.

Assessing the patient's respiratory status directly through respiratory rate and lung sounds will provide more comprehensive information about potential fluid overload and guide further interventions.

Rationale for Choice C:

Measuring the client's temperature is not directly relevant to the concern of rapid fluid administration.

While fever could be a sign of infection, which might warrant fluid administration, it's not the primary concern in this scenario.

The priority is to assess for potential fluid overload, which could manifest as respiratory distress. Rationale for Choice D:

Checking the client's respiratory rate and lung sounds is the most appropriate action for the nurse to take in this situation.

Rapid infusion of 900 mL of fluid within a short period could lead to fluid overload, which can manifest as: Increased respiratory rate

Crackles in the lungs Shortness of breath Hypoxia

Early identification of these signs is crucial for prompt intervention and prevention of serious complications.

A. “Okay then; let me know if you need anything.” B. “That is not bad. C. “I understand you have had the pain for a while. Let’s investigate this further.” D. you know what might be causing the pain?” L. t me know if your pain becomes greater than 4 out of 10; then we can treat it.”

Correct Answer is C

Explanation

Choice A rationale:

This response is dismissive of the patient's pain and does not offer any assistance. It also does not acknowledge the patient's concerns about their pain being a normal part of aging.

It's important to validate the patient's experience and offer support, even if the pain level is not severe.

This response could lead to the patient feeling unheard and unsupported, and it could potentially delay necessary treatment.

Choice B rationale:

This response suggests that the patient's pain is not significant enough to warrant treatment unless it worsens. This is not appropriate, as pain is subjective and should be treated based on the patient's individual experience.

Additionally, this response reinforces the patient's belief that pain is a normal part of aging, which may prevent them from seeking treatment in the future.

Choice C rationale:

This response is the best option because it acknowledges the patient's pain, expresses concern, and suggests further investigation.

It is important to rule out any underlying medical conditions that may be causing the pain.

This response also demonstrates to the patient that the nurse is taking their pain seriously and is committed to helping them manage it.

Choice D rationale:

This response acknowledges that pain can be a part of aging, but it also suggests that there may be a specific cause for the patient's pain.

This could lead to the patient feeling anxious or worried about their health.

It is important to investigate the cause of the pain before making any assumptions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a shift change report, a nurse notices that a patient’s IV bag of 0.9% sodium chloride has 900 mL of fluid remaining.The nurse checks again 30 minutes later and finds that the IV bag is empty. What should the nurse do in this situation?

Correct Answer is D

Explanation

A 79-year-old patient reports a pain level of 3 out of 10 and states, “Don’t worry, this is just part of getting old.” What is the best response?

Correct Answer is C

Explanation

A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus.The client is scheduled for an intravenous pyelogram (IVP). What statements made by the client should the nurse collect additional data about?

Anaphylactic shock is a subgroup of which type of shock?

A nurse enters a client’s room to answer the call light and finds the client on the bathroom floor. What should be the nurse’s initial action?

A nurse is providing care to a group of patients in an adult medical-surgical unit. Which patient should the nurse identify as having the highest risk for aspiration?

A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first?

A nurse on a medical-surgical unit is caring for a patient who is a hospital employee. Several nurses have called seeking information about the patient. What action should the nurse take in response to inquiries from the nurses?

A nurse is attending to a patient with a bowel obstruction who has been prescribed a nasogastric tube. What steps should the nurse take during the insertion of the nasogastric tube?