A charge nurse is making room for new admissions following a community disaster. Which of the following clients should the nurse recommend for discharge?
A client who has a deep-vein thrombosis and an INR of 2.0
A client who is receiving chemotherapy and has tumor lysis syndrome
A client who has a new onset of left-sided weakness
A client who has angina and a troponin level of 3 ng/mL
The Correct Answer is A
Choice A reason: This is the correct choice because this client has the least urgent and most stable condition. A deep-vein thrombosis is a blood clot that forms in a vein, usually in the leg. An INR of 2.0 indicates that the client's blood is within the therapeutic range for anticoagulation therapy, which prevents the clot from growing or breaking off. The nurse should ensure that the client has a prescription for oral anticoagulants, compression stockings, and follow-up appointments before discharging them.
Choice B reason: This is not the correct choice because this client has a serious and potentially life-threatening condition. Tumor lysis syndrome is a complication of chemotherapy that occurs when cancer cells break down rapidly and release their contents into the bloodstream. This can cause electrolyte imbalances, kidney damage, and cardiac arrhythmias. The nurse should monitor the client's vital signs, laboratory values, urine output, and fluid balance, and administer medications and interventions as prescribed.
Choice C reason: This is not the correct choice because this client has a new and acute condition. A new onset of left-sided weakness could indicate a stroke, which is a medical emergency that requires immediate diagnosis and treatment. The nurse should perform a neurological assessment, check the client's blood pressure and blood glucose levels, and activate the stroke protocol.
Choice D reason: This is not the correct choice because this client has a severe and unstable condition. Angina is chest pain that occurs when the heart muscle does not get enough oxygen-rich blood. A troponin level of 3 ng/mL indicates that the client has a high level of cardiac enzymes in the blood, which suggests a heart attack or myocardial infarction. The nurse should administer oxygen, nitroglycerin, aspirin, and morphine as prescribed, and prepare the client for further diagnostic tests and interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A client who has a raised red skin rash on his arms, neck, and face may have an allergic reaction or a skin infection, which are not life-threatening conditions. The nurse should monitor the client for signs of anaphylaxis or systemic infection, but this client is not the highest priority.
Choice B reason: A client who has active bleeding from a puncture wound of the left groin area is the highest priority because they are at risk of hemorrhage and shock. The nurse should apply direct pressure to the wound, elevate the affected leg, and monitor the client's vital signs and hemoglobin level.
Choice C reason: A client who reports shortness of breath and left neck and shoulder pain may have a cardiac or pulmonary problem, such as angina, myocardial infarction, or pulmonary embolism, which are serious conditions. The nurse should obtain an electrocardiogram, administer oxygen, and prepare for further diagnostic tests and interventions, but this client is not the highest priority.
Choice D reason: A client who reports right-sided flank pain and is diaphoretic may have a renal or urinary problem, such as kidney stones, pyelonephritis, or renal colic, which are painful but not life-threatening conditions. The nurse should administer analgesics, encourage fluid intake, and collect a urine sample, but this client is not the highest priority.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because an evidence-based nursing journal is a reliable and credible source of information that is based on research and best practices. A nurse can use an evidence-based nursing journal to find current and accurate data on the prevalence of Tay-Sachs disease, as well as the causes, symptoms, diagnosis, treatment, and prevention of the disease.
Choice B reason: This is not the correct choice because the client's health care provider is not a resource that the nurse should use to obtain information about the prevalence of Tay-Sachs disease. The nurse should respect the client's autonomy and privacy and not contact the client's health care provider without the client's consent. The nurse should also avoid relying on the health care provider's opinion or knowledge, which may not be up to date or consistent with the evidence.
Choice C reason: This is not the correct choice because the facility's case manager is not a resource that the nurse should use to obtain information about the prevalence of Tay-Sachs disease. The case manager's role is to coordinate the client's care and services, not to provide information or education on specific diseases. The case manager may not have the expertise or the access to the relevant information that the nurse needs.
Choice D reason: This is not the correct choice because a collaborative, user-edited website is not a resource that the nurse should use to obtain information about the prevalence of Tay-Sachs disease. A collaborative, user-edited website, such as Wikipedia, is not a reliable or credible source of information, as anyone can edit or add content without verification or peer review. The information on such a website may be outdated, inaccurate, biased, or incomplete.
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