A client who has been hospitalized for two weeks tells the nurse that he wants to go home today because he feels fine now and does not need any more treatment or tests done on him at this time.
The nurse knows that this client is scheduled for a cardiac catheterization tomorrow morning and that his discharge date is not yet determined by his physician.
Which of the following actions should the nurse take first?
Inform the client that he cannot leave without a physician’s order.
Explain the purpose and benefits of the cardiac catheterization to the client.
Assess the client’s understanding and readiness for discharge.
Notify the physician and the charge nurse about the client’s request.
The Correct Answer is C
Assess the client’s understanding and readiness for discharge.
This is the first action that the nurse should take because it allows the nurse to evaluate the client’s mental status, coping skills, and educational needs.
The nurse should also explore the reasons why the client wants to go home and address any concerns or fears that the client may have.
Choice A is wrong because it is not client-centered and may increase the client’s anxiety or anger.
The nurse should not threaten or coerce the client to stay in the hospital against his will.
Choice B is wrong because it is not the priority at this time.
The nurse should first assess the client’s knowledge and willingness to undergo the cardiac catheterization before providing information about it.
Choice D is wrong because it is not the first action that the nurse should take.
The nurse should notify the physician and the charge nurse after assessing the client and documenting the findings.
A cardiac catheterization is a procedure that uses a thin, flexible tube (catheter) to access the heart and blood vessels. It can help diagnose and treat various heart conditions, such as coronary artery disease, heart valve disease, congenital heart defects, or heart failure.
Some of the benefits of cardiac catheterization are:.
• It can provide detailed information about the structure and function of the heart and blood vessels that other tests may not show.
• It can help determine the best treatment plan for the client based on his or her specific condition and needs.
• It can deliver treatments such as angioplasty, stent placement, valve repair or replacement, or device implantation during the same procedure.
• It can reduce the need for more invasive surgery or repeated hospitalizations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Subjective, Objective, Assessment, Plan.This is the meaning of SOAP format, which is a documentation method used by nurses and other healthcare providers to write out notes in the patient’s chart.
Choice B is wrong becauseSituation, Observation, Action, Problemis not a documentation method, but a communication tool used in handovers and briefings.
Choice C is wrong becauseSummary, Outcome, Analysis, Processis not a documentation method, but a framework for writing reflective essays.
Choice D is wrong becauseSource, Opinion, Accuracy, Purposeis not a documentation method, but a criteria for evaluating information sources.
SOAP format helps to organize the information collected from the patient in a clear and consistent manner.
It consists of four components:.
• Subjective: This includes how the patient is feeling and how they have been since the last review in their own words.
• Objective: This includes the objective observations that can be measured, seen, heard, felt or smelled, such as vital signs, fluid balance, clinical examination findings and investigation results.
• Assessment: This includes the thoughts on the salient issues and the diagnosis (or differential diagnosis) based on the subjective and objective data.
• Plan: This includes the actions that will be taken to address the patient’s problems, such as medications, investigations, referrals and follow-ups.
Correct Answer is A
Explanation
Daily weight, blood pressure, and pulse.
A flow sheet is a type of document that records specific information in a structured and concise way, such as vital signs, fluid intake and output, pain level, etc.A flow sheet is useful for clinical communication and tracking the patient’s condition over time.A medication administration record (MAR) is a separate document that records the medications given to the patient, the dosage, the route, and the time.A nursing diagnosis and care plan is a document that identifies the patient’s problems and goals, and the interventions to achieve them.A discharge planning and referral summary is a document that outlines the patient’s needs and resources after leaving the facility, such as follow-up appointments, home care services, etc.
These documents are not part of a flow sheet.
Choice B is wrong because a MAR is not a flow sheet.
Choice C is wrong because a nursing diagnosis and care plan is not a flow sheet.
Choice D is wrong because a discharge planning and referral summary is not a flow sheet.
Normal ranges for daily weight vary depending on the patient’s age, height, gender, and medical condition.However, a general guideline is that a weight gain or loss of more than 2 kg (4.4 lbs) in a week or 0.9 kg (2 lbs) in a day may indicate fluid retention or dehydration.Normal ranges for blood pressure are less than 120/80 mmHg for adults, and less than 95/65 mmHg for children.Normal ranges for pulse are 60 to 100 beats per minute for adults, and 70 to 120 beats per minute for children.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.