A nurse on a medical-surgical unit is preparing to assist with the admission of clients who were injured in a tornado. Which of the following clients should the nurse recommend for discharge to make room for the new admissions?

A client who had a cerebrovascular accident 8 hr ago and received thrombolytic therapy

A client who has cervical cancer and an internal radioactive implant

A client who had a radical mastectomy 36 hr ago and has a surgical drain

A client who had a lobectomy and has a chest tube drainage system

Answer and Explanation

The Correct Answer is C

The client who had a radical mastectomy 36 hours ago and has a surgical drain is the most stable among the given options and is further along in the recovery process. This client may be ready for discharge with appropriate follow-up care instructions, and their bed can be utilized for the incoming clients who were injured in a tornado.

The client who had a cerebrovascular accident 8 hours ago and received thrombolytic therapy requires close monitoring and assessment for complications, such as bleeding or changes in neurological status.

The client with cervical cancer and an internal radioactive implant requires specific precautions and monitoring to ensure radiation safety and to manage any potential side effects or complications.

The client who had a lobectomy and has a chest tube drainage system needs continued monitoring of respiratory status and drainage, as well as close observation for any signs of complications or worsening condition.

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Correct Answer is D

Explanation

A. Maintain low-level lights in common areas.Low-level lighting can increase confusion and the risk of falls, especially for clients with memory loss. It is important to have adequate lighting to promote a safe environment and help with orientation. Well-lit areas can reduce disorientation and anxiety in clients who are confused or have memory issues.

B. Give the client several meal options at lunchtime. For clients with memory loss and confusion, it is better to provide simple choices or pre-selected meals to reduce decision-making stress and confusion.

C. Confront the client regarding inappropriate behavior.Confronting a client with memory loss or confusion about inappropriate behavior can increase agitation, anxiety, and defensive reactions.

D. Use symbols in the communal room signage.Symbols and pictures can help clients with memory loss navigate their environment more easily because they may have difficulty reading or comprehending written language. Visual cues such as symbols in signage can improve orientation and independence, helping the client feel more comfortable in their surroundings.

A. "I will place my newborn face up on a pillow when sleeping." B. "I will make sure that I can fit one finger between the mattress and the side of my newborn's crib." C. "I will attach the pacifier to my newborn's clothing with a string at bedtime:" D. "I will place my newborn's crib near a heat vent during cold weather"

Correct Answer is B

Explanation

The guideline of being able to fit one finger between the mattress and the side of the crib ensures that there is a safe space to prevent entrapment and suffocation risks.

Placing a newborn on a pillow for sleep is unsafe. Infants should be placed on their backs to sleep on a firm, flat surface without pillows, blankets, or soft bedding. This reduces the risk of suffocation or sudden infant death syndrome (SIDS).

Attaching a pacifier to the newborn's clothing with a string is hazardous. Strings and cords pose a strangulation risk. Pacifiers should be used according to safe guidelines, but they should not be attached to the baby's clothing with any type of string or cord.

Placing a newborn's crib near a heat vent can result in overheating, which is a safety concern. It is important to keep the baby's sleep environment at a comfortable temperature without direct exposure to heat sources or drafts

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A nurse on a medical-surgical unit is preparing to assist with the admission of clients who were injured in a tornado. Which of the following clients should the nurse recommend for discharge to make room for the new admissions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an adult day care facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss. Which of the following strategies should the nurse include in the plan?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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