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 A
Explanation
Choice A reason: The client's current location and status are important information that the nurse should include in the report, as they affect the continuity and quality of care. The nurse should also inform the oncoming nurse of the reason and results of the chest x-ray, if available.
Choice B reason: The client's partner's visit is not relevant information that the nurse should include in the report, as it does not affect the client's care plan or outcomes. The nurse should focus on the client's clinical data and needs, not their personal or social information.
Choice C reason: The client's routine vital signs are not specific information that the nurse should include in the report, as they do not reflect the client's current condition or changes. The nurse should provide the actual vital signs values and trends, as well as any interventions or responses related to them.
Choice D reason: The client's occupation is not pertinent information that the nurse should include in the report, as it does not influence the client's care plan or outcomes. The nurse should respect the client's privacy and confidentiality and avoid disclosing unnecessary or sensitive information.
Correct Answer is C
Explanation
Choice A reason: This is not the correct choice because this response is insensitive and unprofessional. The nurse should not blame or criticize the client for signing the consent form, as this may make the client feel guilty or pressured. The nurse should respect the client's autonomy and right to change their mind.
Choice B reason: This is not the correct choice because this response is inadequate and irrelevant. The nurse should not assume that the client needs more information about the surgery, as this may not address the client's underlying reasons for being unsure. The nurse should listen to the client's concerns and provide emotional support.
Choice C reason: This is the correct choice because this response is respectful and reassuring. The nurse should acknowledge the client's feelings and let them know that they have the option to cancel the surgery if they are not comfortable with it. The nurse should also inform the provider and the surgical team about the client's situation and facilitate further discussion if needed.
Choice D reason: This is not the correct choice because this response is inappropriate and unethical. The nurse should not offer medication to the client to help them relax, as this may impair their decision-making capacity and consent. The nurse should not coerce or manipulate the client to undergo the surgery.
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