A charge nurse on a medical-surgical unit is anticipating an emergency response plan following an external disaster in the community. Which of the following current clients should the nurse recommend for early discharge?
A client who has cancer and a sealed radiation implant.
A client who has COPD and a respiratory rate of 24 breaths/min.
A client who is receiving heparin for deep vein thrombosis.
A client who is 1 day postoperative following a cholecystectomy.
The Correct Answer is D
Choice A reason: A client with a sealed radiation implant requires strict precautions and monitoring to prevent radiation exposure to others. Early discharge is unsafe due to ongoing treatment needs, so this client is not suitable, making this incorrect.
Choice B reason: A COPD client with a respiratory rate of 24 breaths/min indicates potential instability, requiring monitoring for exacerbation. Early discharge risks decompensation without ensured stability, so this client is not appropriate, making this incorrect.
Choice C reason: A client receiving heparin for DVT needs continuous anticoagulation and monitoring to prevent embolism. Discharging early risks clotting complications, so this client requires ongoing hospital care, making this incorrect for early discharge.
Choice D reason: A client 1 day post-cholecystectomy, if stable, is often ready for discharge, as this surgery is routine with quick recovery. Freeing this bed supports disaster response, aligning with triage principles, making this the correct choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Applying testosterone gel to the genital region is contraindicated, as it increases irritation and absorption variability. It should be applied to clean, dry skin on the shoulders, upper arms, or abdomen to ensure safety and efficacy, making this action incorrect and unsafe.
Choice B reason: Checking testosterone levels in 1 week is premature, as steady-state levels typically require 2-4 weeks to stabilize. Monitoring too early may yield inaccurate results, leading to improper dose adjustments. This timing is not standard, making it an incorrect instruction.
Choice C reason: Advising the client to wait 1 hour before showering or swimming ensures adequate absorption of testosterone gel through the skin. Premature water exposure can wash off the gel, reducing efficacy. This aligns with manufacturer guidelines, making it the correct action.
Choice D reason: Applying testosterone gel every other day is incorrect, as daily application maintains consistent hormone levels for hypogonadism treatment. Alternate-day dosing disrupts therapeutic levels, reducing effectiveness. Daily use is standard, making this instruction inappropriate for proper administration.
Correct Answer is B
Explanation
Choice A reason: Administering oxygen is premature without assessing the cause of chest heaviness. While hypoxia may occur in aneurysm rupture, stopping exertion reduces cardiovascular demand first, prioritizing safety in a client with an abdominal aortic aneurysm at risk for rupture.
Choice B reason: Having the client sit down is the priority, as chest heaviness may signal aneurysm instability. Rest reduces aortic wall stress and oxygen demand, preventing rupture or dissection, stabilizing the client for further assessment and intervention in this high-risk condition.
Choice C reason: Checking vital signs is important but secondary to stopping exertion. Chest heaviness suggests potential aneurysm rupture, and continued ambulation risks catastrophe. Sitting the client minimizes cardiovascular stress, allowing subsequent vital sign checks to guide further actions effectively.
Choice D reason: Notifying the provider is critical but not first. Chest heaviness requires immediate cessation of activity to reduce aortic pressure. Sitting stabilizes the client, allowing data collection (e.g., vital signs) before provider notification, ensuring urgent intervention for potential aneurysm complications.
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