A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?
Make a referral for social services.
Explain the process of leaving the facility against medical advice.
Contact the facility chaplain to visit with the client.
Encourage the client to continue with inpatient care.
The Correct Answer is A
A. Making a referral for social services is appropriate as they can assist the client with discharge planning, home care services, and resources for palliative care to support the client's wishes.
B. While it is important to explain the risks of leaving against medical advice, the priority is to support the client’s desire to go home, rather than focusing on the potential consequences at this moment.
C. Contacting the facility chaplain could be beneficial for emotional support, but it does not address the immediate need for facilitating the client’s wish to go home.
D. Encouraging the client to continue with inpatient care contradicts their expressed desire to be with family, which is a crucial aspect of their emotional well-being in this situation.
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Related Questions
Correct Answer is D
Explanation
Bradycardia is not typically associated with pulmonary edema; instead, tachycardia is more common as the body tries to compensate for decreased oxygenation.
B. Wheezing may occur in certain respiratory conditions but is not a classic finding in pulmonary edema; instead, crackles or rales are more expected due to fluid accumulation.
C. Pale, dry skin is not characteristic of pulmonary edema; the client may present with cyanosis or clammy skin due to hypoxia.
D. Pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the alveoli and is often associated with acute heart failure.
Correct Answer is B
Explanation
A. Withholding the next dose of warfarin is incorrect. Warfarin takes several days to reach therapeutic levels, and the INR of 1.8 is below the target range (typically 2.0–3.0 for PE treatment). Stopping warfarin is unnecessary.
B. Withholding the heparin infusion is correct. The aPTT is significantly elevated at 98 seconds (therapeutic range: 60–80 seconds for PE treatment), increasing the risk of bleeding. The nurse should pause the heparin infusion and notify the provider for dose adjustment.
C. Preparing to administer vitamin K is incorrect. Vitamin K reverses warfarin effects, but the INR of 1.8 is not dangerously high and does not require reversal.
D. Preparing to administer alteplase is incorrect. Alteplase (a thrombolytic) is used for massive PE with hemodynamic instability, not for a patient already receiving anticoagulation therapy.
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