A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community.
In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
A client who is receiving heparin for deep-vein thrombosis.
A client who is 1 day postoperative following a vertebroplasty.
A client who has cancer and a sealed implant for radiation therapy.
A client who has COPD and a respiratory rate of 44/min.
The Correct Answer is B
The correct answer is choice B. A client who is 1 day postoperative following a vertebroplasty. A vertebroplasty is a procedure that injects cement into a fractured vertebra to help relieve pain and stabilize the spine. The recovery time for this procedure is usually short and the complications are rare.
Therefore, this client is most likely to be stable and ready for early discharge.
Choice A is wrong because a client who is receiving heparin for deep-vein thrombosis (DVT) needs close monitoring of their blood levels and clotting factors. Heparin is a blood thinner that prevents the clots from getting bigger or breaking loose and traveling to the lungs, which can cause a life-threatening condition called pulmonary embolism (PE).
This client is not a good candidate for early discharge.
Choice C is wrong because a client who has cancer and a sealed implant for radiation therapy needs to be isolated in a special room to prevent exposure of others to radiation. A sealed implant is a small holder that contains a radioactive source that is placed inside or near the tumor to deliver high doses of radiation. This type of internal radiation therapy, also called brachytherapy, can last from several minutes to several days, depending on the type and dose of the radioactive source.
This client is not a good candidate for early discharge.
Choice D is wrong because a client who has COPD and a respiratory rate of 44/min has signs of respiratory distress and possible hypoxemia (low oxygen levels in the blood).
COP
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Correct Answer is D
Explanation
The correct answer is choice D. Evaluate the client’s ability to help with repositioning.
This is because the nurse should assess the client’s level of mobility, strength, and coordination before repositioning them to prevent injury and promote comfort.
The nurse should also use appropriate assistive devices, such as a drawsheet, a trapeze bar, or a mechanical lift, to facilitate safe repositioning and reduce the risk of skin breakdown and pressure ulcers.
Choice A is wrong because raising the side rails on both sides of the client’s bed during repositioning can increase the risk of falls and entrapment.
The nurse should only raise the side rail on the opposite side of the bed from where they are working and lower it when they are done.
Choice B is wrong because repositioning the client without assistive devices can cause strain and injury to both the nurse and the client.
The nurse should use assistive devices that are appropriate for the client’s condition and weight.
Choice C is wrong because discussing the client’s preferences for determining a repositioning schedule is not a priority action when preparing to reposition a client who had a stroke.
The nurse should follow the facility’s protocol for repositioning frequency, which is usually every 2 hours, and adjust it according to the client’s needs and comfort.
The nurse should also involve the client in the care plan and respect their preferences whenever possible.
Correct Answer is D
Explanation
The correct answer is choice D. Minimize noise in the newborn’s environment.
This is because neonatal abstinence syndrome (NAS) is a condition that affects newborns who are exposed to opioids or other addictive substances in the womb. These substances can cause withdrawal symptoms in the newborns, such as excessive crying, tremors, vomiting, diarrhea, and seizures.
Minimizing noise and other stimuli can help calm the newborn and reduce stress.
Choice A is wrong because swaddling the newborn with his legs extended can increase muscle tension and discomfort. Swaddling should be done with the legs flexed and hips abducted to prevent hip dysplasia.
Choice B is wrong because administering naloxone to the newborn can cause severe withdrawal symptoms and respiratory depression. Naloxone is an opioid antagonist that reverses the effects of opioids, but it is not recommended for newborns with NAS unless they have life-threatening respiratory depression.
Choice C is wrong because maintaining eye contact with the newborn during feedings can overstimulate the newborn and cause agitation. Eye contact should be avoided or limited during feedings for newborns with NAS.
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