A charge nurse on a medical-surgical unit is anticipating an emergency response plan following an external disaster in the community. Which of the following current clients should the nurse recommend for early discharge?
A client who has cancer and a sealed radiation implant.
A client who has COPD and a respiratory rate of 24 breaths/min.
A client who is receiving heparin for deep vein thrombosis.
A client who is 1 day postoperative following a cholecystectomy.
The Correct Answer is D
Choice A reason: A client with a sealed radiation implant requires strict precautions and monitoring to prevent radiation exposure to others. Early discharge is unsafe due to ongoing treatment needs, so this client is not suitable, making this incorrect.
Choice B reason: A COPD client with a respiratory rate of 24 breaths/min indicates potential instability, requiring monitoring for exacerbation. Early discharge risks decompensation without ensured stability, so this client is not appropriate, making this incorrect.
Choice C reason: A client receiving heparin for DVT needs continuous anticoagulation and monitoring to prevent embolism. Discharging early risks clotting complications, so this client requires ongoing hospital care, making this incorrect for early discharge.
Choice D reason: A client 1 day post-cholecystectomy, if stable, is often ready for discharge, as this surgery is routine with quick recovery. Freeing this bed supports disaster response, aligning with triage principles, making this the correct choice.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Stating immunizations are required for air travel is inaccurate, as no such mandate exists for infants. This response does not address the parents’ concerns or educate them, potentially alienating them, making it ineffective and incorrect for fostering dialogue about immunization.
Choice B reason: Offering a referral to an infectious disease provider is premature and does not directly address the parents’ decision. Education and discussion are needed first to understand their concerns, making this response less effective and inappropriate as an initial approach.
Choice C reason: Suggesting no need to immunize against rare diseases is misleading, as vaccines prevent resurgences (e.g., measles). This undermines public health and dismisses the parents’ concerns, making it incorrect and potentially harmful to the infant’s health.
Choice D reason: Inviting discussion about the parents’ knowledge fosters open, non-judgmental communication, allowing the nurse to address misconceptions and provide evidence-based information. This therapeutic approach builds trust and encourages informed decision-making, making it the correct response for vaccine hesitancy.
Correct Answer is A
Explanation
Choice A reason: Frequent swallowing is a key indicator of post-tonsillectomy hemorrhage, as the child may swallow blood from bleeding in the surgical site. This subtle sign requires urgent assessment to prevent airway obstruction or significant blood loss, aligning with clinical priorities, making it the correct finding.
Choice B reason: Increased drowsiness may indicate pain medication effects or general recovery but is not specific to hemorrhage. While concerning, it is less urgent than frequent swallowing, which directly suggests bleeding, making this finding less indicative of hemorrhage in this context.
Choice C reason: Elevated pain is expected post-tonsillectomy due to surgical trauma and does not specifically indicate hemorrhage. Pain may persist regardless of bleeding, so this finding is less reliable than frequent swallowing for identifying potential hemorrhage, making it incorrect.
Choice D reason: Diminished breath sounds suggest respiratory complications like atelectasis or obstruction, not hemorrhage. Bleeding would more likely present with swallowing or visible blood. This finding is unrelated to tonsillectomy hemorrhage, making it an incorrect indicator for this complication.
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