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
Rationale:
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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Correct Answer is ["B","C","D"]
Explanation
Rationale:
A. Assessing a client requires clinical judgment and should not be delegated to an AP.
B. Accompanying a client to occupational therapy is a task that can be safely assigned to an AP as it does not require clinical judgment.
C. Checking the position of a client in soft wrist restraints is a routine task that can be assigned to an AP as long as the AP has been trained in restraint protocols.
D. Sitting with a client who has alcohol use disorder (5 days after their last drink) is a task that an AP can perform, especially if the client does not require close monitoring for medical complications such as delirium tremens.
E. Setting limits with a client requires therapeutic communication skills and clinical judgment, so this should not be delegated to an AP.
Correct Answer is C
Explanation
Rationale:
A. Urine output of 120 mL in 4 hours is within acceptable limits, especially following anesthesia. Normal output can vary, but 30 mL/hr is often used as a guideline.
B. A systolic blood pressure that is only 12 mm Hg lower than preoperative levels may be concerning, but it does not necessarily require immediate reporting unless other symptoms are present.
C. Audible stridor is a sign of airway obstruction or severe respiratory distress and requires immediate medical attention. It should always be reported to the provider.
D. An occasional premature ventricular contraction (PVC) can be common postoperatively and may not necessitate reporting unless accompanied by significant symptoms or changes in hemodynamic status.