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 A
Explanation
Alcohol withdrawal can often lead to an increase in blood pressure. The autonomic nervous system becomes hyperactive during withdrawal, resulting in increased sympathetic activity, which can elevate blood pressure.
Constipation is not typically associated with alcohol withdrawal. However, chronic alcohol use can affect the gastrointestinal system and lead to digestive issues, including diarrhea or gastrointestinal bleeding.
Polyuria, which refers to excessive urination, is not a typical manifestation of alcohol withdrawal. However, alcohol use can affect fluid balance and lead to changes in urination patterns.
Bradycardia, or a slow heart rate, is not a common manifestation of alcohol withdrawal. Instead, tachycardia (an increased heart rate) is more commonly observed during withdrawal due to the hyperactivity of the autonomic nervous system.
Correct Answer is D
Explanation
Waiting 1 minute between suctioning attempts allows the client to recover and ensures that the procedure is not overly invasive. It also helps to prevent the client from becoming hypoxic.
The distance that the nasopharyngeal catheter should be inserted varies from person to person and therefore 10 cm is not standard.
During nasopharyngeal suctioning, the nurse should apply suction intermittently while withdrawing the catheter, not during insertion. Applying suction during insertion can cause tissue damage and increase the risk of trauma.
The nurse should also apply intermittent suction for no longer than 15 seconds to prevent hypoxia and damage to the mucosal lining. Suctioning for an extended period can cause discomfort and harm to the client.
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