A client who fell and broke a wrist is admitted for 24-hour observation after emergency orthopedic surgery. The healthcare provider prescribes discharge in the morning. Which finding(s) should the nurse use to evaluate the client's status for discharge from the hospital? Select all that apply.
Oral medications, including analgesics, are tolerated without vomiting.
Vital signs within normal limits and blood pressure of 142/94 mm Hg.
Pain rating of 5 on a 0 to 10 scale and taking oral analgesics every 4 hours.
Client is able to ambulate to the bathroom safely to void.
Bowel sounds are present in all four quadrants and abdomen is soft.
Correct Answer : A,D
Choice A reason: Tolerating oral medications without vomiting is essential for discharge to ensure the client can manage pain and take necessary medications at home.
Choice B reason: While vital signs are important, the slightly elevated blood pressure alone may not prevent discharge if other criteria are met.
Choice C reason: A pain rating of 5 managed with oral analgesics is acceptable for discharge if the client can manage pain at home.
Choice D reason: Being able to ambulate to the bathroom safely is crucial for discharge to ensure the client can independently manage basic needs.
Choice E reason: Bowel sounds and a soft abdomen are important but are not the primary criteria for discharge in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Encouraging rest may not relieve the pain; sitting up and leaning forward is a common position for relief in pancreatitis.
Choice B reason: Positioning the bedside table allows the client to lean forward comfortably and may help alleviate the pain.
Choice C reason: Raising the head of the bed to a 90-degree angle may not provide the same relief as leaning forward.
Choice D reason: Reverse Trendelenburg position is not specifically indicated for pancreatitis pain relief.
Correct Answer is B
Explanation
Choice A reason: Continuing with the blood pressure assessment without acknowledging the auscultatory gap may result in an inaccurate reading.
Choice B reason: Noting the presence of an auscultatory gap is important as it indicates a brief period when Korotkoff sounds disappear and then reappear, which can lead to underestimation of systolic blood pressure and overestimation of diastolic blood pressure if not recognized.
Choice C reason: Repositioning the stethoscope may not address the issue of the auscultatory gap and may lead to inaccurate readings.
Choice D reason: Re-inflating the cuff to a higher number is unnecessary and may cause discomfort without addressing the auscultatory gap.
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