A charge nurse on a medical-surgical unit is reviewing the electronic medical record on a group of clients during a mass casualty event.
Client 3
Client 4
Client 2
Client 1
Client 5
Correct Answer : A,C
Rationale:
A. Client 3: The client is 4 days post–total hip replacement, ambulating well with assistance, and stable. This client is appropriate for discharge to free up beds.
B. Client 4: The client has COPD with a high fever and thick blood-tinged sputum, indicating acute illness that requires continued hospitalization.
C. Client 2: The client is preoperative for bariatric surgery, which can potentially be postponed or discharged preoperatively if stable, making them suitable for discharge in a mass casualty scenario.
D. Client 1: The client has ongoing chest pain with recent nitroglycerin use and cardiac monitoring, requiring continued inpatient care.
E. Client 5: The client is hypotensive and tachycardic due to dehydration, requiring ongoing IV fluids and monitoring, so discharge is unsafe.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Client concerns about meals should be addressed but do not require an incident report—these can be managed through dietary services or routine documentation.
B. Difficulty obtaining medication from the pharmacy is a systems issue, but it does not directly involve a client safety event and therefore does not require an incident report.
C. A client’s refusal of medication is their right and should be documented in the medical record, not reported as an incident.
D. Withholding a client’s scheduled medication constitutes a medication error/variance, which directly affects client safety and must be documented using an incident report.
Correct Answer is ["C","D","E"]
Explanation
Rationale:
A. Initiating IV access while a client with dementia is sleeping violates autonomy and informed consent—this is not advocacy.
B. Implementing a plan of care based on nursing goals reflects nursing practice, but advocacy focuses on protecting the client’s rights and wishes, not just following nursing objectives.
C. Providing written information about palliative care supports informed decision-making, which is a key aspect of advocacy.
D. Obtaining an interpreter ensures the client understands their care and can make informed decisions, which is an advocacy action.
E. Documenting a client’s refusal of medication respects and upholds the client’s autonomy, which is a form of advocacy.
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