A nurse is recommending clients for discharge to allow for admission of clients following a tornado disaster. Which of the following clients should the nurse recommend for discharge?
A client who has a sodium level of 140 mEq/L after one episode of diarrhea.
A client who is 3 days postoperative following a hip arthroplasty and has a warm, red area on his left calf.
A client who has atrial fibrillation and an INR of 4.
A client who reports chest pain after ambulating.
The Correct Answer is A
A. "A client who has a sodium level of 140 mEq/L after one episode of diarrhea." This is the correct choice. A sodium level of 140 mEq/L is within the normal range, and the client has had only one episode of diarrhea, suggesting that they are stable and could be safely discharged.
B. "A client who is 3 days postoperative following a hip arthroplasty and has a warm, red area on his left calf." This is a concern. The warm, red area on the calf could indicate the presence of a deep vein thrombosis (DVT) or infection, both of which require further evaluation and management.
C. "A client who has atrial fibrillation and an INR of 4." This is concerning. An INR of 4 indicates an increased risk of bleeding, which requires closer monitoring and potentially adjusting the anticoagulation therapy before discharge.
D. "A client who reports chest pain after ambulating." This is an urgent issue that needs immediate attention. Chest pain could indicate a serious cardiac event, such as a myocardial infarction, and the client should not be discharged until further evaluation is performed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Holding the irrigation solution bottle 5 cm (2 in) above the sterile container is incorrect because the solution should be poured into a sterile container without contaminating the sterile field. The nurse should pour the solution from a height that avoids splashing and contamination.
B. Opening the outer wrapper of the sterile package toward her body is incorrect. The outer wrapper of a sterile package should be opened away from the body to avoid contamination of the sterile field.
C. Placing the irrigation solution bottle cap on the sterile field is incorrect. The cap should not be placed on the sterile field, as it may introduce contaminants.
D. Placing sterile objects at least 2.5 cm (1 in) from the edge of the sterile field is correct. This practice maintains the sterility of the field by preventing contamination from external sources.
Correct Answer is C
Explanation
A. "Eat 40 milligrams of protein-rich foods per day.": Protein intake is important during pregnancy, but 40 milligrams is an unusually low amount. The recommended amount is generally higher, around 71 grams of protein per day during pregnancy.
B. "Increase your dietary intake by 500 calories per day.": The general recommendation for calorie increase during pregnancy is about 300 calories per day, not 500. 500 calories per day may be recommended in specific situations, but it is not the typical guideline.
C. "Consume 600 micrograms of folic acid per day.": This is the correct recommendation. The CDC and other health guidelines recommend that pregnant individuals consume 400-600 micrograms of folic acid daily to prevent neural tube defects.
D. "Limit your caffeine intake to 700 milligrams per day.": Caffeine intake should generally be limited to around 200-300 milligrams per day during pregnancy, not 700 milligrams, as high caffeine intake can have adverse effects on pregnancy outcomes.
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