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 C
Explanation
Choice A reason: This is not the correct way to transcribe a verbal prescription. The nurse should not use decimals or trailing zeros when writing doses, as they can be misread or mistaken for larger doses. For example, 10.0 mg could be read as 100 mg.
Choice B reason: This is not the correct way to transcribe a verbal prescription. The nurse should not use abbreviations that are not approved by the facility or the Joint Commission, as they can be confusing or ambiguous. For example, MSO4 could be confused with magnesium sulfate (MgSO4).
Choice C reason: This is the correct way to transcribe a verbal prescription. The nurse should write the full name of the drug, the dose, the route, the frequency, and the indication for use. The nurse should also use standard abbreviations that are clear and unambiguous. For example, IV means intravenous, q4h means every 4 hours, and prn means as needed.
Choice D reason: This is not the correct way to transcribe a verbal prescription. The nurse should not use abbreviations that are not approved by the facility or the Joint Commission, as they can be confusing or ambiguous. For example, MS could be confused with morphine sulfate or magnesium sulfate. The nurse should also use standard abbreviations for the route and frequency, not words like every or prn.
Correct Answer is B
Explanation
Choice A reason: Information regarding organ donation is not part of advance directives, but rather a separate document that the client can sign to indicate their willingness to donate their organs or tissues after death. The nurse should inform the client about the option and process of organ donation, but not include it in the advance directives.
Choice B reason: Instructions regarding treatments the client desires or does not desire is part of advance directives, as it allows the client to express their preferences and values regarding their health care in case they become unable to make decisions for themselves. The nurse should help the client understand the benefits and risks of different treatments and document their choices in the advance directives.
Choice C reason: Information regarding the disposition of the client's body upon death is not part of advance directives, but rather a personal or legal matter that the client can arrange with their family or attorney. The nurse should respect the client's wishes regarding their body after death, but not include it in the advance directives.
Choice D reason: A form with directions for contacting next of kin is not part of advance directives, but rather a routine document that the client can fill out when they are admitted to the facility. The nurse should obtain the client's contact information and emergency contacts, but not include it in the advance directives.
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