A nurse on a medical-surgical unit is preparing to assist with the admission of clients who were injured in a tornado. Which of the following clients should the nurse recommend for discharge to make room for the new admissions?
A client who had a cerebrovascular accident 8 hr ago and received thrombolytic therapy
A client who has cervical cancer and an internal radioactive implant
A client who had a radical mastectomy 36 hr ago and has a surgical drain
A client who had a lobectomy and has a chest tube drainage system
The Correct Answer is C
The client who had a radical mastectomy 36 hours ago and has a surgical drain is the most stable among the given options and is further along in the recovery process. This client may be ready for discharge with appropriate follow-up care instructions, and their bed can be utilized for the incoming clients who were injured in a tornado.
The client who had a cerebrovascular accident 8 hours ago and received thrombolytic therapy requires close monitoring and assessment for complications, such as bleeding or changes in neurological status.
The client with cervical cancer and an internal radioactive implant requires specific precautions and monitoring to ensure radiation safety and to manage any potential side effects or complications.
The client who had a lobectomy and has a chest tube drainage system needs continued monitoring of respiratory status and drainage, as well as close observation for any signs of complications or worsening condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This statement demonstrates an understanding of the concept of spacing out immunizations to reduce the number of shots given during a single visit. By making multiple office visits, the parent can ensure that their child receives the recommended immunizations while minimizing the number of injections at each visit.
Lactose intolerance is not a contraindication to receiving immunizations. Most vaccines do not contain lactose, and even if they do, the amount present is typically minimal and not expected to cause an adverse reaction in individuals with lactose intolerance.
The first flu immunization is typically recommended for children starting at 6 months of age, not at 6 years of age.
The human papillomavirus (HPV) vaccine is typically recommended for preteens and adolescents, usually starting between the ages of 11 and 12. It is not typically administered when a child enters kindergarten.
Correct Answer is C
Explanation
A.While monitoring the client's physical condition, including range of motion, is important, it typically needs to be done more frequently than every 60 minutes. The Joint Commission and other regulatory bodies often recommend continuous observation and checks every 15 minutes.
B.Typically, a provider's order for restraints must be obtained immediately or within a very short time frame (often within an hour), not 48 hours. Regulations vary but generally require prompt notification and authorization.
C.Restraints should only be used as a last resort and for the shortest duration possible. The goal is to ensure the client's safety and the safety of others while minimizing the use of restraints. Removing the restraints as soon as the client is calm and no longer a threat to themselves or others is essential to respecting the client's rights and promoting their dignity.
D.Offer the client a nutritious snack every 4 hr.: While providing nutrition and hydration is important, the primary focus immediately after applying restraints should be on the client's safety and the frequent assessment of their condition. Offering a snack every 4 hours is not the immediate priority in this context.
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