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 C

Explanation

A. Providing the client's breakfast is an essential aspect of diabetes care, but obtaining information about the client's blood glucose level is a priority before administering insulin or making decisions about meal planning.

B. Obtaining the client's capillary blood glucose level is a critical first step. Knowing the current blood glucose level guides the nurse in determining the appropriate insulin dosage, assessing the need for any adjustments in the treatment plan, and planning the client's breakfast based on their current glucose level.

C. Checking the calibration of the glucometer is the first action to ensure the accuracy of the blood glucose measurement. Regular calibration checks help maintain the precision of the glucometer and ensure reliable results.

D. Administering prescribed insulin is an important step in managing type 1 diabetes, but the dosage should be determined based on the client's current blood glucose level. Administering insulin without knowing the current glucose level could lead to inappropriate dosage and potential complications.

A. Instruct the client to limit flexion of the hips no further than 100". B. Perform range-of-motion exercises every 2 hr. C. Reposition the client every 2 hr. D. Place an abduction pillow between the legs.

Correct Answer is A

Explanation

A. Instruct the client to limit flexion of the hips no further than 100°.For a client who is postoperative following a total hip arthroplasty, hip flexion should generally be limited to 90° or less to avoid dislocation of the hip prosthesis. The instruction to limit flexion to 100° could potentially put the client at risk for dislocation and should be clarified.

B. Perform range-of-motion exercises every 2 hr.This helps prevent stiffness and promotes circulation, although passive range of motion should be performed carefully to avoid excessive hip flexion.

C. Reposition the client every 2 hr.Regular repositioning helps prevent pressure ulcers and other complications, and is a standard postoperative practice.

D. Place an abduction pillow between the legs.An abduction pillow is used to keep the legs apart and prevent dislocation of the hip joint, which is essential after a hip arthroplasty.

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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

Naxlex Comprehensive Predictor Exams

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