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: This is the correct choice because this information is relevant and important for the physical therapist. A hemoglobin of 5 g/dL indicates severe anemia, which can cause fatigue, weakness, shortness of breath, and palpitations. The physical therapist should be aware of the client's condition and adjust the therapy accordingly. The physical therapist should also monitor the client's vital signs, oxygen saturation, and tolerance to activity.
Choice B reason: This is not the correct choice because this information is not relevant or important for the physical therapist. A clean-catch urine test is a diagnostic test that requires the client to collect a midstream urine sample in a sterile container. The physical therapist does not need to know about this test or its results, as it does not affect the client's physical therapy.
Choice C reason: This is not the correct choice because this information is not relevant or important for the physical therapist. Opioid-induced constipation is a side effect of opioid medications that can cause abdominal pain, bloating, and difficulty passing stools. The physical therapist does not need to know about this condition or its treatment, as it does not affect the client's physical therapy.
Choice D reason: This is not the correct choice because this information is not relevant or important for the physical therapist. A new diagnosis of colorectal cancer is a serious and life-changing condition that requires medical and surgical interventions. The physical therapist does not need to know about this diagnosis or its prognosis, as it does not affect the client's physical therapy.
Correct Answer is A
Explanation
Choice A reason: This is the correct response by the nurse. The nurse should respect the client's right to privacy and confidentiality and not disclose any information about the client's treatment plan without the client's consent. The nurse should also inform the adult child that they can ask their mother for permission to access her medical records.
Choice B reason: This is not the correct response by the nurse. The nurse should not ask the adult child what they want to know about the client's treatment, as this implies that the nurse is willing to share the information without the client's consent. The nurse should only answer the questions that the client has authorized the nurse to answer.
Choice C reason: This is not the correct response by the nurse. The nurse should not tell the adult child to speak directly to their mother about her treatment, as this may put pressure on the client to reveal information that she may not want to share. The nurse should respect the client's autonomy and decision-making regarding her treatment plan.
Choice D reason: This is not the correct response by the nurse. The nurse should not ask the client's primary care provider to speak with the adult child, as this may violate the client's privacy and confidentiality. The nurse should only involve the primary care provider if the client has given consent or if there is a legal or ethical obligation to do so.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today