A nurse is 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 ascites and had a paracentesis 4 hr ago

A client who is 6 hr postoperative following a hip arthroplasty

A client who has a blood glucose level of 380 mg/dL and is receiving insulin via IV infusion

A client who has pneumonia and is receiving 100% oxygen via a nonrebreather mask

Answer and Explanation

The Correct Answer is A

This client has undergone a paracentesis for ascites, and since it was done 4 hours ago, they are likely stable and can be considered for discharge.

The client who is 6 hours postoperative following a hip arthroplasty may still require close monitoring and postoperative care. Discharging a postoperative client too early could lead to complications.

The client with a blood glucose level of 380 mg/dL receiving insulin via IV infusion requires ongoing monitoring and management of their diabetes. Discharging this client during an external disaster may not be appropriate due to the need for continued medical intervention.

The client with pneumonia receiving 100% oxygen via a nonrebreather mask likely requires continued medical attention and monitoring. Discharging a client with pneumonia who requires high-flow oxygen can pose risks to their respiratory status.

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Correct Answer is B

Explanation

A. While scheduling an appointment with the prosthetist is important, the client's comfort and pain control take precedence, especially in the immediate postoperative period. Addressing pain concerns is a priority to ensure the client's well-being.

B. "Do you feel your pain is controlled well?" is the first question to ask. Assessing pain is crucial to understanding the client's level of comfort and ensuring that appropriate measures are in place for pain management. This information can guide further interventions and adjustments to the care plan.

C. Inquiring about support groups in the area is an important aspect of the client's overall well-being and adjustment to the amputation. However, pain control is an immediate concern, and addressing it takes precedence during the initial home visit.

D. Asking about exercising other extremities is relevant for the client's overall mobility and

rehabilitation. However, pain control assessment should be prioritized as it directly impacts the client's ability to participate in rehabilitation activities.

A. Incentive spirometer B. Continuous positive airway pressure machine C. Yankauer suction equipment D. Nebulizer

Correct Answer is B

Explanation

A. Incentive spirometer:

An incentive spirometer is used to encourage deep breathing and prevent respiratory complications, but it is not specifically indicated for the management of sleep apnea.

B. Continuous positive airway pressure (CPAP) machine.

The description of the client stopping breathing for 30-second intervals while sleeping at night is suggestive of sleep apnea. A Continuous Positive Airway Pressure (CPAP) machine is commonly used for the management of sleep apnea. It delivers a continuous stream of air to keep the airway open, preventing pauses in breathing during sleep.

C. Yankauer suction equipment:

Yankauer suction equipment is used for oral suctioning and is not related to addressing the breathing pauses associated with sleep apnea.

D. Nebulizer:

A nebulizer is used to administer inhaled medications, typically for respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD). It is not the primary equipment for addressing the respiratory pauses seen in sleep apnea.

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

Nursing Test Bank

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