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 C
Explanation
A. Auscultate the client's lung sounds: While assessing lung sounds is an important part of the overall assessment for a client with heart failure (to check for pulmonary edema/crackles), it is not a specific requirement for the administration of digoxin. It helps evaluate the effectiveness of the treatment over time but does not determine if the current dose is safe to give.
B. Check the client's weight: Daily weights are essential for monitoring fluid volume status in heart failure patients. However, like lung sounds, this is an assessment of the disease progression rather than a safety check for the medication's immediate effect on the heart's electrical system.
C. Check the client's apical pulse: Digoxin can cause bradycardia and other arrhythmias. The nurse must assess the apical pulse for a full minute before administration and withhold the medication if the rate is below the provider’s prescribed parameters (commonly <60 bpm in adults).
D. Obtain the client's oxygen saturation: Oxygen saturation provides information about respiratory status but does not directly influence the decision to administer digoxin.
Correct Answer is C
Explanation
A. Assist the client with dangling off the side of the bed: While mobilization can help prevent complications such as atelectasis or thromboembolism, it does not address the immediate concern of a possible postoperative infection indicated by the elevated temperature.
B. Obtain a prescription to check the client's CBC: Ordering a CBC can help identify infection or inflammation, but it is a diagnostic action that follows initial assessment. Immediate assessment of potential sources of infection takes priority.
C. Check the condition of the client's surgical incision: Assessing the surgical site is the first action because an incision can be a primary source of infection in postoperative clients. Early identification of redness, drainage, or other signs of infection allows prompt intervention.
D. Instruct the client to breathe deeply and cough: Deep breathing and coughing are important for preventing respiratory complications, but they do not address the urgent need to assess for infection, which is indicated by the elevated temperature.
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