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. Tinnitus with ear pain: While tinnitus can be a side effect of some medications, it is not associated with Stevens-Johnson syndrome (SJS). This symptom is more common with other medications or conditions, like aspirin or certain antibiotics, but not allopurinol.
B. Diplopia: Diplopia (double vision) is not a common sign of Stevens-Johnson syndrome. This symptom could be related to other conditions but is not characteristic of SJS.
C. Hyperreflexia: Hyperreflexia is not a typical manifestation of Stevens-Johnson syndrome. While neurological symptoms may sometimes occur, they are not central to the diagnosis of SJS.
D. Skin rash with fever: A skin rash with fever is a classic early sign of Stevens-Johnson syndrome. It is a potentially life-threatening reaction to certain medications, including allopurinol, and requires immediate medical attention. The rash often begins with a mild erythema, which may progress to blistering and sloughing of the skin.
Correct Answer is D
Explanation
A. Increased appetite: Radiation therapy, particularly to the head and neck, can cause nausea, mouth sores, and changes in taste, leading to a decrease in appetite rather than an increase.
B. Loose stools: Loose stools are not a typical side effect of external radiation for throat cancer. Radiation can affect gastrointestinal function if the abdomen or pelvis is irradiated, but it is not commonly associated with the throat area.
C. Bladder infection: Bladder infections are more likely to be associated with treatments like chemotherapy or radiation to the pelvic region, rather than radiation to the throat.
D. Loss of taste: Radiation therapy to the head and neck, including the throat, often affects the taste buds, leading to a condition called dysgeusia, or loss of taste. This is a well-known side effect of radiation in this area.
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