A nurse is preparing for an incoming storm. Which of the following clients should the nurse recommend for discharge planning?
An infant who has respiratory syncytial virus and a respiratory rate of 70b/min
An adolescent who has cystic fibrosis and is receiving their yearly tune-up
A child who has a new diagnosis of type 1 diabetes mellitus and is receiving IV insulin
A child who has leukemia and an absolute neutrophil count of 200/mm3 (2,500 to 8,000/mm3
The Correct Answer is B
A. An infant who has respiratory syncytial virus and a respiratory rate of 70/min: This infant is experiencing tachypnea, which indicates respiratory distress. Discharging during a storm would place the infant at high risk for decompensation and inadequate access to emergency care.
B. An adolescent who has cystic fibrosis and is receiving their yearly tune-up: A routine annual check-up indicates the adolescent is stable and does not require acute care. This client is the safest candidate for discharge during a storm, as their condition is not immediately life-threatening.
C. A child who has a new diagnosis of type 1 diabetes mellitus and is receiving IV insulin: This child requires close monitoring and titration of insulin therapy, making discharge unsafe. Early management of new-onset diabetes involves frequent assessments that cannot be delayed.
D. A child who has leukemia and an absolute neutrophil count of 200/mm³: Severe neutropenia places the child at high risk for infection. Discharge during a storm could prevent timely access to emergency care if complications arise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Wrap the sleeve loosely around the client's lower leg: The sleeve should fit snugly but comfortably to ensure effective compression. Wrapping it too loosely reduces efficacy in promoting venous return and preventing deep vein thrombosis. Proper fit is essential for device function and patient safety.
B. Measure the circumference of the client's upper leg: Measuring the thigh circumference ensures the correct sleeve size is selected, which is crucial for effective compression and prevention of pressure injury. Accurate sizing allows the device to deliver appropriate pressure without causing discomfort or circulatory compromise.
C. Turn on the mechanical unit prior to applying the sleeve: The device should remain off until the sleeve is properly positioned on the client. Activating it beforehand may result in improper inflation, skin injury, or ineffective compression. Turning it on too early can also startle the client and reduce comfort.
D. Position the client prone to apply the device: The client should be supine or with legs slightly elevated when applying a thigh-length sequential compression device. Prone positioning is unnecessary, uncomfortable, and can complicate proper sleeve placement. Supine positioning facilitates correct alignment and device effectiveness.
Correct Answer is D
Explanation
A. Hypertension: Hyponatremia typically does not cause high blood pressure. In fact, low sodium levels can lead to fluid shifts and hypotension in severe cases, rather than hypertension. Monitoring blood pressure is important, but hypertension is not an expected finding of hyponatremia.
B. Blurred vision: Blurred vision is not a classic symptom of hyponatremia. While severe electrolyte imbalances can affect neurological function, visual changes are more commonly associated with hypernatremia or other conditions affecting the eyes.
C. Constipation: Constipation is not directly linked to low sodium levels. Hyponatremia primarily affects neuromuscular and neurological function, rather than gastrointestinal motility.
D. Muscle cramps: Muscle cramps are a common manifestation of hyponatremia due to the disruption of sodium’s role in neuromuscular excitability. Low sodium levels can cause involuntary muscle contractions, weakness, and twitching.
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