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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Inform the charge nurse. The charge nurse should be notified when consent cannot be obtained so appropriate steps can be taken, such as rescheduling or involving the healthcare provider.
B. Send the client for the test with the unsigned form. Consent must be obtained before any invasive procedure. Proceeding without consent can result in legal and ethical consequences.
C. Obtain consent from a family member. A family member cannot give consent unless they hold legal power of attorney for healthcare decisions.
D. Wake the client and ask them to sign the form. Consent obtained under the influence of sedatives is not legally valid as it compromises the client's decision-making capacity.

A. Pain medication is administered 1 hr before a client has a dressing change. B. The same indwelling urinary catheter is reinserted after a failed attempt. C. Medications scheduled four times a day are administered 2 hr after the scheduled time. D. Finger nail marks appear on a client's wrist after a radial pulse was taken. E. A sublingual medication is crushed and administered through a client's gastrostomy tube.

Correct Answer is ["B","C","D","E"]

Explanation

A. Pain medication is administered 1 hr before a client has a dressing change. Administering pain medication before a painful procedure is appropriate and respects the client’s comfort needs.
B. The same indwelling urinary catheter is reinserted after a failed attempt. Reinserting the same catheter increases the risk of infection and violates infection control guidelines.
C. Medications scheduled four times a day are administered 2 hr after the scheduled time. This represents a medication administration error and violates safe medication administration practices.
D. Finger nail marks appear on a client's wrist after a radial pulse was taken. This may suggest physical harm, which is a violation of the client's right to safety.
E. A sublingual medication is crushed and administered through a client's gastrostomy tube. Sublingual medications are designed for absorption under the tongue and should not be altered, as doing so can affect efficacy and absorption.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for an invasive procedure that requires consent. When the nurse arrives at the bedside to obtain the client's signature they find that the client is asleep after receiving a sedative. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a group of newly licensed nurses about client rights. Which of the following scenarios should the nurse include as an example of a client rights violation for which a nurse should intervene? (Select all that apply).

Correct Answer is ["B","C","D","E"]

Explanation

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