A charge nurse is recommending postpartum clients for discharge following a local disaster. Which of the following clients should the nurse recommend for discharge first?
A client who had an emergency cesarean birth 1 day ago
A client who had a precipitous birth 36 hr ago and has a second-degree perineal laceration
A client who has preeclampsia and a blood pressure of 166/110 mm Hg
A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
The Correct Answer is B
A. A client 1 day post-cesarean birth is still at risk for postoperative complications (e.g., infection, bleeding, pain, immobility). This client requires ongoing hospital monitoring.
B. A client who delivered vaginally 36 hours ago and has only a second-degree laceration is generally stable and can safely be discharged home with proper instructions for perineal care.
C. The client with preeclampsia and severe hypertension (166/110 mm Hg) is at high risk for seizures, stroke, and organ complications. This client must remain hospitalized for stabilization and management.
D. A client recently transfused after postpartum hemorrhage needs continued monitoring for recurrent bleeding and transfusion reactions. Discharging this client would be unsafe.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
The nurse should first address the client’s electrolyte imbalancefollowed by the client’s obsession with food.
Rationale:
Electrolyte imbalance: The client has low potassium (3 mEq/L) and low sodium (134 mEq/L), along with a history of recurrent vomiting. Electrolyte disturbances place the client at immediate risk for cardiac dysrhythmias, as evidenced by PVCs on ECG. This is a life-threatening priority according to the ABCs and Maslow’s hierarchy of needs, so it must be addressed first.
Obsession with food: Once the immediate physiological risk is stabilized, the nurse should address the psychological aspect of bulimia, including the client’s preoccupation with food, binge-purge behaviors, and distorted eating patterns. This aligns with holistic care and ongoing mental health management.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
Rationale:
Aspiration: The client has high gastric residual volumes (220 mL at 0800, 280 mL at 0900) while receiving enteral feedings via NG tube. Delayed gastric emptying increases the risk that stomach contents could reflux and enter the lungs, causing aspiration pneumonia. Continuous monitoring and potentially holding or adjusting feedings are indicated.
Skin breakdown: The client is postoperative, has an NG tube, limited mobility, and is experiencing pain that may reduce movement. These factors, combined with urine output changes and potential incontinence, increase the risk for pressure ulcers and skin breakdown at pressure points.
Other risks such as bleeding, hyperglycemia, and urinary retention are less immediate given the client’s current assessment and lab/vital signs.
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