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 A
Explanation
A. Covering the wound with sterile, saline-soaked gauze is correct. Evisceration occurs when abdominal contents protrude through a surgical wound. To prevent drying and further tissue damage, the nurse should immediately cover the exposed organs with sterile gauze moistened with saline to maintain moisture and reduce infection risk.
B. Holding gentle, direct pressure on the protruding organ is incorrect. Applying pressure can cause further damage to the exposed tissue and increase the risk of complications. Instead, the focus should be on protecting the organs and minimizing contamination.
C. Placing the client’s knees in an extended position is incorrect. Keeping the knees straight can increase tension on the wound. Instead, the nurse should position the client with the knees slightly flexed to reduce strain on the abdominal incision.
D. Raising the head of the bed to a 45° angle is incorrect. A high Fowler’s position can increase pressure on the wound. The nurse should place the client in a low Fowler’s position (supine with knees slightly flexed. to reduce tension and prevent further protrusion.
Correct Answer is A
Explanation
A. Injecting 15 units of air into the regular insulin vial is correct. When drawing up two types of insulin, the nurse should first inject air into the NPH (cloudy) insulin vial without withdrawing the medication. Then, the nurse should inject air into the regular (clear) insulin vial before withdrawing the regular insulin. This prevents contamination and maintains proper insulin mixing procedures.
B. Placing the cap over the needle is incorrect. Once insulin preparation has started, recapping the needle is unnecessary and increases the risk of contamination or needlestick injury.
C. Verifying the dosage with another nurse is incorrect at this stage. Dosage verification should be done after the correct amounts of insulin are drawn into the syringe, not before.
D. Withdrawing 10 units of NPH insulin is incorrect. The nurse should first withdraw the regular (clear) insulin before drawing up the NPH (cloudy) insulin to avoid contaminating the regular insulin with the longer-acting insulin.
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