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 {"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Becoming isolated and withdrawn: While concerning, the risk is lower than active command hallucinations, making this a lower priority for immediate assessment.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. Perform CPR for a client who is not breathing. B. Complete distal capillary refill checks for a client who has an open leg wound. C. Determine which clients need priority medical treatment. D. Answer questions from area residents who have health concerns.

Correct Answer is D

Explanation

A. Perform CPR for a client who is not breathing: CPR is within the scope of trained assistive personnel, but a nurse or advanced provider typically manages it in an emergency scenario.
B. Complete distal capillary refill checks for a client who has an open leg wound: Capillary refill checks require clinical assessment skills, which are outside the AP's scope of practice.
C. Determine which clients need priority medical treatment: Triage and prioritization require clinical judgment, which is the nurse's responsibility.
D. Answer questions from area residents who have health concerns: APs can answer non-clinical questions and provide basic information to area residents.

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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 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

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Correct Answer is D

Explanation

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