A nurse is assisting with selecting clients for discharge due to a local external disaster. Which of the following clients should the nurse recommend for discharge?
A client who has pneumonia and is receiving 100% oxygen via a non rebreather mask.
A client who has ascites and had a paracentesis 4 hr ago.
A client who has a blood glucose level of 380 mg/dL (74 to 106 mg/dL) and is receiving insulin via IV infusion.
A client who is 6 hr postoperative following a hip arthroplasty.
The Correct Answer is B
A. A client who has pneumonia and is receiving 100% oxygen via a non-rebreather mask: This client requires intensive respiratory care and cannot be safely discharged.
B. A client who has ascites and had a paracentesis 4 hr ago: This client is stable following a low-risk outpatient procedure and can be safely managed at home.
C. A client who has a blood glucose level of 380 mg/dL and is receiving insulin via IV infusion: This client has poorly controlled hyperglycemia requiring close monitoring and treatment.
D. A client who is 6 hr postoperative following a hip arthroplasty: This client requires postoperative monitoring and pain management and is at risk for complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
A. Client 5 (Streptococcal pharyngitis): Proper isolation and precautions were implemented, including a private room and surgical mask during transport. No follow-up is needed.
B. Client 4 (Mycobacterium tuberculosis): Requires follow-up. Tuberculosis requires a negative pressure room, not a positive airflow room. Positive airflow rooms are used for clients who need protection from outside pathogens, such as those who are immunocompromised.
C. Client 3 (Herpes simplex): Correct precautions were implemented. Herpes simplex (when involving open lesions) requires contact precautions, including gown and gloves. No follow-up is necessary.
D. Client 2 (Clostridium difficile): Appropriate precautions were taken, including a private room and the use of gown and gloves for direct care. No follow-up is needed.
E. Client 1 (Pertussis): Requires follow-up. Pertussis is transmitted via respiratory droplets, but placing the client in a negative pressure room is unnecessary. Droplet precautions (standard private room and surgical mask use within 3 feet) are sufficient. Negative pressure rooms are reserved for airborne infections such as tuberculosis.
Correct Answer is ["B","C","D"]
Explanation
A. Client 1: Worsening of the pressure injury with purulent drainage indicates infection and failure of pressure injury prevention strategies.
B. Client 5: The stage 3 pressure injury reduced in size and severity to stage 2, with the absence of purulent drainage, indicating wound healing and effective intervention.
C. Client 2: WBC count decreased from 11,500/mm³ to within the normal range at 9,500/mm³, indicating improvement in pneumonia.
D. Client 3: Temperature reduced from 38.9°C to 38°C, with stabilization of vital signs, suggesting improvement in the wound infection.
E. Client 4: An increase in WBCs in the urine from 2 to 6 per low-power field suggests worsening of the urinary tract infection, indicating program ineffectiveness.
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