A nurse on a medical-surgical unit is caring for a client who states that she plans to leave the facility against medical advice. For which of the following actions by the nurse should the charge nurse intervene?
Asks the client what her plans are for follow-up care
Asks the client to sign a form releasing the hospital from legal responsibility
Shows the client her abnormal laboratory results
Asks security to detain the client until the provider is notified
None
None
The Correct Answer is D
Rationale:
A. Asks the client what her plans are for follow-up care: This is an appropriate action that demonstrates concern for the client’s continuity of care and safety, even if she decides to leave against medical advice.
B. Asks the client to sign a form releasing the hospital from legal responsibility: This is standard practice when a client leaves against medical advice, as it documents that the client was informed of potential risks and chose to leave voluntarily. This action is appropriate and does not require the charge nurse to intervene.
C. Shows the client her abnormal laboratory results: Providing relevant medical information is appropriate to help the client make an informed decision about her care before leaving the facility.
D. Asks security to detain the client until the provider is notified: Clients have the legal right to leave a healthcare facility unless they are under specific legal or mental health holds. Detaining a competent adult against their will is unlawful and violates patient rights hence requiring intervention by the charge nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "This medication can cause back pain.": Back pain is not a common or expected adverse effect of warfarin. Teaching should focus on bleeding risks and precautions rather than unrelated symptoms.
B. "Avoid taking this medication with milk products.": Milk does not significantly affect warfarin absorption. The main dietary consideration is maintaining consistent vitamin K intake, as large fluctuations can alter anticoagulation.
C. "Use an electric razor when shaving while taking this medication.": Warfarin increases the risk of bleeding and bruising. Using an electric razor reduces the chance of cuts, promoting safety during routine grooming.
D. "Avoid prolonged exposure to sunlight while taking this medication.": Sun exposure is not contraindicated with warfarin; there is no significant interaction between warfarin and UV light.
Correct Answer is A
Explanation
Rationale:
A. Weight loss: Furosemide is a loop diuretic that promotes excretion of excess fluid through urine. A reduction in body weight reflects fluid loss and indicates that the medication is effectively managing fluid volume excess.
B. Decreased inflammation: Furosemide does not have anti-inflammatory properties. While it may reduce edema associated with fluid overload, it does not directly affect inflammatory processes in tissues.
C. Decreased pain: Pain reduction is not a direct effect of furosemide. Any perceived relief might occur secondarily if edema-related pressure is relieved, but it is not a primary measure of medication effectiveness.
D. Increased blood pressure: Furosemide typically lowers blood pressure by reducing intravascular volume. An increase in blood pressure would suggest that fluid overload is not being adequately managed or that another condition is influencing blood pressure.
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