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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Arms raised above her head with her legs elevated on pillows: This is not an appropriate position for a lumbar puncture. The positioning is not ideal for access to the lumbar region and would be uncomfortable for the client.

B. Prone with her arms at her side and her legs extended: While this position may be used for certain procedures, it is not the most appropriate position for a lumbar puncture, which requires specific spinal positioning to access the subarachnoid space effectively.

C. Trendelenburg with her body in Sims' position: Trendelenburg involves positioning the client with the head lower than the feet, which is not necessary for a lumbar puncture and could interfere with the procedure. The Sims' position is more suited for certain other procedures.

D. Head flexed to the chest and her knees pulled up to the abdomen: This is correct. The client should be in a fetal position, with the head flexed toward the chest and the knees pulled up toward the abdomen. This position helps to widen the intervertebral spaces and facilitates easier access for the lumbar puncture.

A. Erythema B. Edema C. Blood D. Pruritus

Correct Answer is B

Explanation

A. Erythema is a sign of infection or irritation, not fluid infiltration. Fluid infiltration typically does not cause redness or inflammation.

B. Edema is correct. Fluid infiltration occurs when the IV catheter becomes displaced and the fluid leaks into the surrounding tissue, causing swelling (edema. at the insertion site.

C. Blood would suggest either an accidental dislodging of the catheter or a complication such as hematoma formation, but it is not a sign of fluid infiltration.

D. Pruritus (itching) is typically associated with an allergic reaction, not fluid infiltration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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