A nurse is assisting with selecting clients for discharge due to a local external disaster. Which of the following clients should the nurse recommend for discharge?

A client who has pneumonia and is receiving 100% oxygen via a non rebreather mask.

A client who has ascites and had a paracentesis 4 hr ago.

A client who has a blood glucose level of 380 mg/dL (74 to 106 mg/dL) and is receiving insulin via IV infusion.

A client who is 6 hr postoperative following a hip arthroplasty.

Answer and Explanation

The Correct Answer is B

A.   A client who has pneumonia and is receiving 100% oxygen via a non-rebreather mask: This client requires intensive respiratory care and cannot be safely discharged.
B.   A client who has ascites and had a paracentesis 4 hr ago: This client is stable following a low-risk outpatient procedure and can be safely managed at home.
C.   A client who has a blood glucose level of 380 mg/dL and is receiving insulin via IV infusion: This client has poorly controlled hyperglycemia requiring close monitoring and treatment.
D.   A client who is 6 hr postoperative following a hip arthroplasty: This client requires postoperative monitoring and pain management and is at risk for complications.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

Client 1 (First Priority):

Experiencing command hallucinations: Command hallucinations are auditory hallucinations that instruct the client to harm themselves or others, posing an immediate safety concern.
Potential risk of self-harm: Persecutory delusions and statements indicating "the agents are watching" suggest escalating paranoia, increasing the risk of dangerous behaviors or impulsive self-protective actions. Immediate intervention is essential to prevent harm.

Client 2 (Lower Priority):

Stopped taking medication: Non-compliance with medication has led to severe depressive symptoms, including isolation, withdrawal, and psychomotor retardation.
Becoming isolated and withdrawn: While concerning, the risk is lower than active command hallucinations, making this a lower priority for immediate assessment. However, this client requires evaluation soon after Client 1.

Client 3 (Lowest Priority):

Low lithium level (0.7 mEq/L): This level is slightly below the therapeutic range (0.8 to 1.2 mEq/L) but not critically dangerous.
Increased risk of agitation and instability: The symptoms of agitation and poor sleep are concerning, but immediate safety threats are less imminent compared to command hallucinations.

A. Inform the charge nurse. B. Send the client for the test with the unsigned form. C. Obtain consent from a family member. D. Wake the client and ask them to sign the form.

Correct Answer is A

Explanation

A. Inform the charge nurse. The charge nurse should be notified when consent cannot be obtained so appropriate steps can be taken, such as rescheduling or involving the healthcare provider.
B. Send the client for the test with the unsigned form. Consent must be obtained before any invasive procedure. Proceeding without consent can result in legal and ethical consequences.
C. Obtain consent from a family member. A family member cannot give consent unless they hold legal power of attorney for healthcare decisions.
D. Wake the client and ask them to sign the form. Consent obtained under the influence of sedatives is not legally valid as it compromises the client's decision-making capacity.

View Question and Answer

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

A nurse is assisting with selecting clients for discharge due to a local external disaster. Which of the following clients should the nurse recommend for discharge?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse on a mental health unit is receiving a change of shift report for a group of clients. Exhibits Complete the following sentence by using the lists of options. The nurse should first collect data from dropdowndue to dropdownanddropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

A nurse is caring for a client who has a prescription for an invasive procedure that requires consent. When the nurse arrives at the bedside to obtain the client's signature they find that the client is asleep after receiving a sedative. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assisting in a client education class for fire safety in the home. Which of the following statements by a client indicates an understanding of the teaching?

A nurse is assisting in the review of infection control precautions implemented by staff in a facility. Exhibits Select 2 client situations that require follow-up by the infection control nurse.

A nurse is serving on a committee that is developing infectious disease protocols. Which of the following instructions should the nurse include in the protocol for clients who have Clostridium difficile?

A nurse receives a change-of-shift report and learns that one of their assigned clients is scheduled to receive a blood transfusion. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a group of assistive personnel about fire evacuation procedures. Which of the following information should the nurse include in the teaching?

A nurse is reviewing the electronic medical records of clients following the implementation of a quality improvement plan to reduce health care associated infections. Exhibits Select the three clients whose findings indicate the program is effective.

A nurse is assisting with the plan of care for a child whose parents refuse to accept the medical treatment prescribed by the provider. Which of the following actions should the nurse plan to take first to address this ethical dilemma?

A nurse is caring for a group of clients in a medical-surgical unit. The nurse should ensure that the client has signed an informed consent form prior to which of the following procedures? (Select all that apply.)