A nurse is selecting clients for discharge due to a local external disaster. Which of the following clients should the nurse recommend for discharge?
A client who has ascites and had a paracentesis 4 hr ago
A client who is 6 hr postoperative following a hip arthroplasty
A client who has a blood glucose level of 380 mg/dL and is receiving insulin via IV infusion
A client who has pneumonia and is receiving 100% oxygen via a nonrebreather mask
The Correct Answer is A
This client has undergone a paracentesis for ascites, and since it was done 4 hours ago, they are likely stable and can be considered for discharge.
The client who is 6 hours postoperative following a hip arthroplasty may still require close monitoring and postoperative care. Discharging a postoperative client too early could lead to complications.
The client with a blood glucose level of 380 mg/dL receiving insulin via IV infusion requires ongoing monitoring and management of their diabetes. Discharging this client during an external disaster may not be appropriate due to the need for continued medical intervention.
The client with pneumonia receiving 100% oxygen via a nonrebreather mask likely requires continued medical attention and monitoring. Discharging a client with pneumonia who requires high-flow oxygen can pose risks to their respiratory status.
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Related Questions
Correct Answer is C
Explanation
A. Report the occurrence to the nursing supervisor:
While reporting the occurrence is important, verifying the DNR status takes precedence. The nurse needs to gather information and confirm whether the patient has a current DNR order before escalating the issue to a higher authority.
B. Complete an incident report stating the facts of the situation:
Completing an incident report is a part of the process, but it should not be the first action. The immediate concern is to determine if the patient has a valid DNR order. An incident report can be completed later to document the situation and any actions taken.
C. Verify the DNR prescription is current in the medical record.
Verifying the DNR (do-not-resuscitate) prescription is the first and most immediate action the nurse should take. It is crucial to confirm the current status of the DNR order to ensure that the healthcare team is following the patient's wishes. If the DNR is indeed valid and up-to-date, it means the resuscitation efforts, including CPR, were contrary to the patient's expressed wishes.
D. Request a meeting with the ethics committee:
Contacting the ethics committee may be necessary depending on the circumstances, but it is not the first step. Verifying the DNR status is an immediate action that can guide subsequent decisions. If there are ethical concerns or conflicts, involving the ethics committee can be considered after confirming the facts surrounding the DNR order.
Correct Answer is D
Explanation
A. Complete medication reconciliation when a client moves to a new room on the same unit:
While it's important to update the client's information when they change rooms, this may not necessitate a full medication reconciliation. Medication reconciliation is typically more comprehensive and involves a thorough review of the client's entire medication regimen.
B. Medication reconciliation should be completed whenever the nurse administers a medication:
While it's important to verify medications before administration, a full medication reconciliation involves a broader review of the client's entire medication history and should not necessarily be done each time a single medication is administered.
C. Medication reconciliation can be delegated to an assistive personnel:
Medication reconciliation is a complex process that involves a thorough review of the client's medication history, and it is generally considered a nursing responsibility. Delegating this task to assistive personnel may compromise accuracy and completeness.
D. Include herbal supplements in the medication reconciliation:
This is the correct answer. Herbal supplements can interact with prescribed medications and may impact the client's overall health. Including them in the medication reconciliation process ensures a comprehensive assessment of the client's medication regimen.
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