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.

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Correct Answer is A

Explanation

A. Advance directives: Advance directives may contain information about the client's wishes for organ donation, along with other end-of-life preferences.
B. Informed consent: Informed consent is related to specific treatments or procedures and does not address organ donation.
C. Provider's prescription: Providers do not write prescriptions for organ donation; it is a legal decision made by the client.
D. Do-not-resuscitate (DNR) order: A DNR order only indicates that no resuscitation should be attempted in the event of cardiac or respiratory arrest.

A. Obtain informed consent from the client for the blood transfusion. B. Delegate the client's care to an RN. C. Access the nursing information system for guidelines about blood transfusions. D. Inform the charge nurse of the need to reassign the client's care.

Correct Answer is C

Explanation

A. Obtain informed consent from the client for the blood transfusion: Verifying that informed consent is obtained is essential, but obtaining consent is the provider's responsibility. The nurse's role is to ensure the consent has been signed and documented.
B. Delegate the client's care to an RN: If the nurse receiving the shift report is already an RN, delegating the care to another RN is unnecessary unless there are specific time constraints or workload considerations.
C. Access the nursing information system for guidelines about blood transfusions: This is an appropriate action to ensure that institutional policies and guidelines are followed regarding blood administration, which may include steps for patient identification, infusion rates, and monitoring for reactions.
D. Inform the charge nurse of the need to reassign the client's care: This is typically not necessary unless the assigned nurse lacks the competency to administer blood products or has competing responsibilities that prevent safe monitoring of the transfusion.

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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 nurse is caring for a client who is scheduled for surgery. While reviewing the client’s medical record the nurse notes the client is an organ donor. Which of the following documents provides information about organ donation?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

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