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 D
Explanation
A. Maintain IV access. This task requires nursing knowledge and skill to ensure patency and medication administration during a code.
B. Assist with airway intubation. This is a complex procedure that requires advanced training and is performed by licensed personnel.
C. Place defibrillator pads on the client. This task should be performed by trained personnel familiar with defibrillator use and cardiac arrest protocols.
D. Perform CPR on the client. CPR is within the scope of an assistive personnel's responsibilities if they are trained in Basic Life Support (BLS).
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
|
Client |
Tag colour |
Rationale |
|
Client 1 |
Red |
The significant blood loss and tourniquet application indicate immediate life-threatening injuries that are survivable with prompt intervention. The heart rate of 54/min is concerning for hypovolemic shock. |
|
Client 2 |
Black |
Fixed and dilated pupils, no pulse, and no spontaneous respirations indicate the client is deceased or has non-survivable injuries. |
|
Client 3 |
Red |
Disorientation, multiple lacerations with significant bleeding, and elevated heart and respiratory rates indicate hemodynamic instability requiring immediate intervention. |
|
Client 4 |
Yellow |
The client is stable, with a suspected arm fracture and minor abrasions. Treatment can be delayed without significant risk of deterioration. |
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