A charge nurse on a medical-surgical unit is reviewing the electronic medical record on a group of clients during a mass casualty event.
Client 3
Client 4
Client 2
Client 1
Client 5
Correct Answer : A,C
Rationale:
A. Client 3: The client is 4 days post–total hip replacement, ambulating well with assistance, and stable. This client is appropriate for discharge to free up beds.
B. Client 4: The client has COPD with a high fever and thick blood-tinged sputum, indicating acute illness that requires continued hospitalization.
C. Client 2: The client is preoperative for bariatric surgery, which can potentially be postponed or discharged preoperatively if stable, making them suitable for discharge in a mass casualty scenario.
D. Client 1: The client has ongoing chest pain with recent nitroglycerin use and cardiac monitoring, requiring continued inpatient care.
E. Client 5: The client is hypotensive and tachycardic due to dehydration, requiring ongoing IV fluids and monitoring, so discharge is unsafe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Facial numbness after a thyroidectomy suggests hypocalcemia, likely due to parathyroid gland injury, and places the client at risk for laryngeal spasms and airway obstruction. This is the priority client.
B. Pain with voiding from acute pyelonephritis is important but not immediately life-threatening.
C. Teaching about insulin administration is necessary but not urgent compared to airway compromise.
D. Clear liquid stools before a colon resection are expected and indicate proper bowel preparation, not an urgent concern.
Correct Answer is B
Explanation
Rationale:
A. Restarting an infiltrated IV is important for antibiotic therapy, but the dose is not due until 0900, so it is not the immediate priority.
B. Insulin aspart is a rapid-acting insulin that peaks quickly. The client must eat promptly to prevent hypoglycemia, making this the highest priority.
C. Administering pain medication for rheumatoid arthritis is necessary, but this is not life-threatening and can be addressed after preventing hypoglycemia.
D. Replacing an enteral feeding solution that has been hanging for 24 hr is important for infection control, but it is not as urgent as preventing acute hypoglycemia.
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