A nurse manager is reviewing medical records to recommend clients for discharge following a local mass casualty event. Which of the following clients should the nurse recommend for discharge?

A client who has heart failure and received furosemide IV 8 hr ago

A client who was admitted 24 hr ago with chest pain

A client who had a seizure 48 hr ago and is on seizure precautions

A client who is scheduled to have a colonoscopy in 12 hr

Answer and Explanation

The Correct Answer is D

A. A client who has heart failure and received furosemide IV 8 hr ago:
Clients with heart failure require ongoing monitoring for fluid balance, electrolyte levels, and signs of worsening symptoms. IV furosemide indicates active treatment, so this client is not stable for discharge.

B. A client who was admitted 24 hr ago with chest pain:
A client with recent chest pain requires further evaluation for acute coronary syndrome (ACS). Even if pain has resolved, monitoring for cardiac events is essential. This client is not stable for discharge.

C. A client who had a seizure 48 hr ago and is on seizure precautions:
Recent seizures require continued monitoring to assess for recurrence, medication adjustments, and safety precautions. This client is not stable for discharge.

D. A client who is scheduled to have a colonoscopy in 12 hr:
A colonoscopy is an elective procedure and does not require hospitalization. This client is stable and can be discharged to free up resources for mass casualty victims.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Ensure 2 cm (0.8 in) of water is in the water seal chamber. This is correct because maintaining the correct water level in the water seal chamber is essential for proper functioning of the chest tube system, as it prevents air from entering the pleural space.
B. Check the patency of the tubing every 2 hr. This is incorrect because continuous monitoring is required, and patency should be ensured at all times, not just at set intervals. However, frequent assessments are important.
C. Keep the drainage system above the level of the client's chest. This is incorrect because the drainage system should be kept below chest level to allow gravity drainage and prevent backflow into the pleural space.
D. Empty the collection chamber every 8 hr. This is incorrect because the collection chamber should only be emptied when full, following facility protocol, to maintain an accurate record of drainage output.

A. Help the client to identify effective past coping skills. B. Initiate precautions to safeguard the client from physical harm. C. Assist the client to identify available support systems. D. Encourage the client to express feelings about the incident.

Correct Answer is B

Explanation

A. Identifying past coping skills is important but is not the priority in a crisis situation where the client's safety is at risk.
B. Ensuring the client’s immediate safety is the priority because they may still be in danger from the abusive partner. Crisis intervention focuses first on protecting the client from further harm.
C. Identifying support systems is beneficial for long-term recovery but does not take precedence over ensuring the client’s immediate safety.
D. Encouraging expression of feelings is therapeutic, but the priority is to remove the client from immediate harm before addressing emotional needs.

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A nurse manager is reviewing medical records to recommend clients for discharge following a local mass casualty event. 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 has a three-chamber chest tube system. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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