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 D
Explanation
Choice A reason: This is not the correct choice because this action is not legally required or ethically appropriate. The client has the right to refuse treatment and leave the hospital at any time, as long as she is competent and informed of the risks and consequences. The nurse should not coerce or threaten the client to stay against her will.
Choice B reason: This is not the correct choice because this action is not helpful or respectful. The client may have valid reasons for wanting to go home, such as personal or financial issues. The nurse should not assume that the client is anxious or irrational and offer her a sedative, which may impair her judgment and consent.
Choice C reason: This is not the correct choice because this action is not necessary or professional. The client is not a threat to herself or others, and does not need to be restrained or guarded by a security officer. The nurse should not use intimidation or force to prevent the client from leaving.
Choice D reason: This is the correct choice because this action is the best practice and the standard procedure. The nurse should explain to the client the benefits of staying and the risks of leaving, and document the conversation. The nurse should also ask the client to sign the Against Medical Advice form, which states that the client understands the implications of her decision and releases the hospital and the provider from liability.
Correct Answer is B
Explanation
A. The client’s aPTT is within the therapeutic range for heparin, so immediate interdisciplinary discussion is not required.
B. Clients using insulin pumps require coordination between the nurse, endocrinologist, and diabetes educator to ensure safe insulin administration and blood glucose management, making an interdisciplinary conference appropriate.
C. Orthostatic hypotension being managed with IV fluids can typically be addressed within routine nursing care without needing an interdisciplinary meeting.
D. The client’s albumin level is within normal limits, and risk for pressure injuries can be managed with standard nursing interventions without requiring a conference.
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