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 A

Explanation

Choice A reason: A history of suicide attempts is crucial information when planning the care of a client using heroin because there is a high risk of further suicide attempts, especially in individuals with substance use disorders. The nurse must prioritize mental health safety and implement measures to monitor and support the client's psychological well-being to prevent any potential self-harm.

Choice B reason: While family history of schizophrenia is important, it is not immediately crucial to the plan of care for a client currently using heroin. This information is more relevant for long-term monitoring and psychiatric evaluation rather than immediate care planning.

Choice C reason: Undiagnosed social anxiety disorder (SAD) may contribute to substance use; however, it is not the most urgent concern in this scenario. The focus should be on immediate safety and stabilization, particularly addressing the high risk of suicide.

Choice D reason: Feelings of disorientation are significant but could be a result of heroin use. While important to assess, they are secondary to the immediate concern of preventing self-harm in a client with a history of suicide attempts.

A. Evaluate a client's mobility progress toward the plan of care. B. Titrate oxygen to the prescribed parameters. C. Procure platelet products from the blood bank. D. Determine the diameter and depth of a client's dermal ulcer.

Correct Answer is C

Explanation

Choice A reason: Evaluating a client's mobility progress involves assessment and clinical judgment, which are beyond the scope of practice for a UAP.

Choice B reason: Titrating oxygen requires clinical judgment and understanding of the client's condition, which should be performed by licensed nursing staff.

Choice C reason: Procuring platelet products from the blood bank is within the scope of practice for a UAP as it involves following protocols and retrieving items, not direct patient care.

Choice D reason: Determining the diameter and depth of a client's dermal ulcer involves assessment and clinical judgment, which should be performed by licensed nursing staff.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

Correct Answer is A

Explanation

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the UAP?

Correct Answer is C

Explanation

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?

A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.