A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community.
In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
A client who is receiving heparin for deep-vein thrombosis.
A client who is 1 day postoperative following a vertebroplasty.
A client who has cancer and a sealed implant for radiation therapy.
A client who has COPD and a respiratory rate of 44/min.
The Correct Answer is B
The correct answer is choice B. A client who is 1 day postoperative following a vertebroplasty. A vertebroplasty is a procedure that injects cement into a fractured vertebra to help relieve pain and stabilize the spine. The recovery time for this procedure is usually short and the complications are rare.
Therefore, this client is most likely to be stable and ready for early discharge.
Choice A is wrong because a client who is receiving heparin for deep-vein thrombosis (DVT) needs close monitoring of their blood levels and clotting factors. Heparin is a blood thinner that prevents the clots from getting bigger or breaking loose and traveling to the lungs, which can cause a life-threatening condition called pulmonary embolism (PE).
This client is not a good candidate for early discharge.
Choice C is wrong because a client who has cancer and a sealed implant for radiation therapy needs to be isolated in a special room to prevent exposure of others to radiation. A sealed implant is a small holder that contains a radioactive source that is placed inside or near the tumor to deliver high doses of radiation. This type of internal radiation therapy, also called brachytherapy, can last from several minutes to several days, depending on the type and dose of the radioactive source.
This client is not a good candidate for early discharge.
Choice D is wrong because a client who has COPD and a respiratory rate of 44/min has signs of respiratory distress and possible hypoxemia (low oxygen levels in the blood).
COP
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. “Perform chest percussion and postural drainage at least twice daily.” This is because chest percussion and postural drainage are airway clearance techniques that help remove thick mucus from the lungs of children who have cystic fibrosis. This can prevent respiratory infections and improve lung function.
Choice A is wrong because a bronchodilator should be administered before airway clearance therapy, not after. A bronchodilator helps open up the airways and make it easier to cough up mucus.
Choice B is wrong because pancreatic enzymes should be administered with meals and snacks, not on an empty stomach.
Pancreatic enzymes help digest fats, proteins, and carbohydrates in children who have cystic fibrosis. This can prevent malnutrition and growth failure.
Choice D is wrong because there is no need to restrict gluten intake for children who have cystic fibrosis, unless they also have celiac disease.
Gluten is a protein found in wheat, barley, and rye that can cause intestinal damage in people who have celiac disease. Cystic fibrosis does not affect the ability to tolerate gluten.
Correct Answer is B
Explanation
The correct answer is B.
Previous violent behavior. According to the web search results, this is the best predictor of future violence among the given risk factors.
Other risk factors include past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders).
Choice A is wrong because a history of being in prison is not a direct cause of violence, but rather a possible consequence of it.
Choice C is wrong because male gender is not a sufficient factor to predict violence, as there are many other variables involved. Choice D is wrong because experiencing delusions is not necessarily associated with violence, unless they are of a paranoid or persecutory nature.
Normal ranges for violence risk assessment are not standardized, but some tools that can be used include the Historical Clinical Risk Management-20 (HCR-20), the Violence Risk Appraisal Guide (VRAG), and the Psychopathy Checklist-Revised (PCL-R). These tools use different scales and criteria to evaluate the likelihood of violent behavior in individuals.
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