A client who fell and broke a wrist is admitted for 24-hour observation after emergency orthopedic surgery. The healthcare provider prescribes discharge in the morning. Which finding(s) should the nurse use to evaluate the client's status for discharge from the hospital? Select all that apply.

Oral medications, including analgesics, are tolerated without vomiting.

Vital signs within normal limits and blood pressure of 142/94 mm Hg.

Pain rating of 5 on a 0 to 10 scale and taking oral analgesics every 4 hours.

Client is able to ambulate to the bathroom safely to void.

Bowel sounds are present in all four quadrants and abdomen is soft.

Answer and Explanation

Correct Answer : A,D

Choice A reason: Tolerating oral medications without vomiting is essential for discharge to ensure the client can manage pain and take necessary medications at home.

Choice B reason: While vital signs are important, the slightly elevated blood pressure alone may not prevent discharge if other criteria are met.

Choice C reason: A pain rating of 5 managed with oral analgesics is acceptable for discharge if the client can manage pain at home.

Choice D reason: Being able to ambulate to the bathroom safely is crucial for discharge to ensure the client can independently manage basic needs.

Choice E reason: Bowel sounds and a soft abdomen are important but are not the primary criteria for discharge in this context.

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Correct Answer is B

Explanation

Choice A reason: Scarlet fever and pneumonia require droplet precautions, not airborne.

Choice B reason: A positive Mantoux test and positive sputum cultures for AFB indicate tuberculosis, which requires airborne precautions and a negative airflow room.

Choice C reason: Scabies requires contact precautions, not airborne.

Choice D reason: Genital Herpes simplex II requires standard precautions, not airborne.

A. Don an N95 respirator mask, face shield, gown, gloves, and shoe coverings prior to returning to the room. B. Explain to the client to inform others that they may have been potentially exposed in the last 14 days. C. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus. D. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility.

Correct Answer is A

Explanation

Choice A reason: Donning appropriate personal protective equipment (PPE) is the most important action to protect the healthcare provider and prevent the spread of the virus while caring for the client.

Choice B reason: Explaining to the client to inform others about potential exposure is important but can be done after ensuring the nurse's safety with proper PPE.

Choice C reason: Teaching the client to wear a mask, hand wash, and social distance is important for preventing the spread of the virus but is not the immediate priority.

Choice D reason: Notifying the charge nurse about the need for assignment to a COVID-19 specified area is necessary for infection control but follows the immediate action of donning PPE.

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A client who fell and broke a wrist is admitted for 24-hour observation after emergency orthopedic surgery. The healthcare provider prescribes discharge in the morning. Which finding(s) should the nurse use to evaluate the client's status for discharge from the hospital? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Correct Answer is B

Explanation

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

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