A nurse manager is reviewing medical records to recommend clients for discharge following a local mass casualty event. Which of the following clients should the nurse recommend for discharge?
A client who has heart failure and received furosemide IV 8 hr ago
A client who was admitted 24 hr ago with chest pain
A client who had a seizure 48 hr ago and is on seizure precautions
A client who is scheduled to have a colonoscopy in 12 hr
The Correct Answer is D
A. A client who has heart failure and received furosemide IV 8 hr ago:
Clients with heart failure require ongoing monitoring for fluid balance, electrolyte levels, and signs of worsening symptoms. IV furosemide indicates active treatment, so this client is not stable for discharge.
B. A client who was admitted 24 hr ago with chest pain:
A client with recent chest pain requires further evaluation for acute coronary syndrome (ACS). Even if pain has resolved, monitoring for cardiac events is essential. This client is not stable for discharge.
C. A client who had a seizure 48 hr ago and is on seizure precautions:
Recent seizures require continued monitoring to assess for recurrence, medication adjustments, and safety precautions. This client is not stable for discharge.
D. A client who is scheduled to have a colonoscopy in 12 hr:
A colonoscopy is an elective procedure and does not require hospitalization. This client is stable and can be discharged to free up resources for mass casualty victims.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Losartan is an angiotensin II receptor blocker (ARB) used to treat hypertension, so it does not cause hypertension. Instead, it lowers blood pressure.
B. Dizziness is a common adverse effect of losartan due to its blood pressure-lowering effects, which can lead to orthostatic hypotension.
C. Double vision is not a known adverse effect of losartan.
D. Losartan does not cause hyperactivity; it is more likely to cause fatigue or weakness.
Correct Answer is ["B","D"]
Explanation
A. Blood pressure: The client’s BP is 128/84 mm Hg, which is within the normal range. Although the client has chronic hypertension, this BP reading does not indicate an immediate concern.
B. Fetal heart rate: The fetal heart rate (FHR) is 165/min, which is tachycardia (normal FHR range is 110–160/min). Fetal tachycardia can indicate infection, maternal fever, fetal distress, or hypoxia and requires immediate follow-up.
C. Fetal station: The station is 0, which means the presenting part is at the level of the ischial spines. This is normal for a laboring client at 4 cm dilation and does not require immediate intervention.
D. Characteristics of amniotic fluid: The fluid is green, indicating the presence of meconium-stained amniotic fluid, which suggests fetal distress or hypoxia. This requires immediate follow-up, as the baby is at risk for meconium aspiration syndrome.
E. Duration of contraction: The contraction lasted 40 seconds, which is within the normal range (30–90 seconds). This is not an immediate concern.
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