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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Complete an incident report.
Reporting a needlestick injury through an incident report is crucial. It documents the details of the incident, which is important for the nurse's safety and for initiating appropriate follow-up actions.
B. Receive a hepatitis C immunization:
There is no specific hepatitis C vaccine available. While there are vaccines for hepatitis A and hepatitis B, there is currently no vaccine to prevent hepatitis C. Seeking post-exposure prophylaxis and follow-up is more relevant in this case.
C. Notify the health department:
Notifying the health department might be necessary in some cases, but the immediate action for the nurse is to report the incident through an incident report within the facility. This allows for prompt internal investigation and necessary measures.
D. Start prophylactic antibiotic therapy:
Prophylactic antibiotic therapy is not the standard protocol for preventing hepatitis C transmission after a needlestick injury. Antiviral medications might be considered in certain cases for post-exposure prophylaxis for hepatitis C, but this decision should be made after consulting with a healthcare provider or infectious disease specialist based on the specific circumstances of the exposure. Reporting the incident remains the immediate priority.
Correct Answer is B
Explanation
A.Opening windows during a fire can increase airflow, which may actually intensify the flames and spread the fire faster. Instead, clients should close doors to contain the fire and smoke, stay low to the ground to avoid inhaling smoke, and focus on evacuating the home safely.
B.Storing the fire extinguisher away from the stove ensures it remains accessible if a fire breaks out on or near the stove. If a fire occurs, the extinguisher should be in a location that is easy to access but away from the immediate fire source to prevent the person from reaching through flames to retrieve it.
C.The correct technique is to aim the nozzle at the base of the flames, where the fuel source is. This helps to smother the fire more effectively, as aiming at the base cuts off the fuel source, whereas aiming at the top would be less effective.
D.The batteries in smoke alarms should generally be changed every 6-12 months to ensure they are functioning properly. Many recommendations also suggest testing alarms monthly and replacing the entire smoke alarm every 10 years.
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