The charge nurse in a critical care unit is reviewing client conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit?

Reference Range:

Hemoglobin (Hgb) [14 to 18 g/dL (140 to 180 g/L)]

Adult respiratory distress syndrome with an oxygen saturation of 88% on room air.

Chronic liver failure with a hemoglobin of 10.1 g/dL (101 g/L) and a slight bilirubin elevation.

Myocardial infarction with sinus bradycardia and multiple ectopic beats.

Pulmonary embolus with an IV heparin infusion and new onset hematuria.

Answer and Explanation

The Correct Answer is B

A. Adult respiratory distress syndrome with an oxygen saturation of 88% on room air is unstable. Hypoxemia at this level requires intensive monitoring and possibly mechanical ventilation or high-flow oxygen, making the client unsafe for transfer to a lower-acuity medical unit.

B. Chronic liver failure with a hemoglobin of 10.1 g/dL (101 g/L) and a slight bilirubin elevation is stable enough for transfer. Although the client has mild anemia and liver enzyme changes, vital signs and overall stability are likely maintained, and this condition can be managed safely on a medical unit with routine monitoring and care.

C. Myocardial infarction with sinus bradycardia and multiple ectopic beats indicates ongoing cardiac instability. This client requires continuous cardiac monitoring, potential interventions for arrhythmias, and close hemodynamic observation, which cannot be safely provided outside the critical care unit.

D. Pulmonary embolus with an IV heparin infusion and new onset hematuria is unstable. The new hematuria suggests a bleeding complication, and the client requires close monitoring and potential adjustment of anticoagulation therapy in the critical care setting.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Giving the spouse a straw to help the client drink is premature and potentially dangerous. After a cerebrovascular accident (CVA), clients with facial paralysis and hemiplegia are at high risk for dysphagia, and the use of a straw could increase the likelihood of aspiration. Aspiration can lead to serious complications such as pneumonia or airway obstruction, so it is unsafe to provide fluids in this manner without first assessing swallowing ability.

B. Obtaining thickening powder before offering fluids may be necessary later if the client is cleared for oral intake, but this step does not address the immediate concern. The client may not yet be safe to take any fluids by mouth. Administering thickened liquids without a swallowing assessment could still result in choking or aspiration if the client cannot coordinate swallowing effectively.

C. Asking the spouse to stop and assessing the client’s swallowing reflex is the correct and priority action. The nurse must ensure the client can safely swallow before allowing any oral intake. Swallowing assessment includes evaluating the gag reflex, observing for coughing, drooling, or difficulty managing saliva, and determining the client’s ability to handle liquids safely. This step protects the client from aspiration, which is a common and potentially life-threatening complication following a CVA. Once the assessment is completed, the nurse can determine whether safe feeding strategies, such as thickened liquids or modified feeding techniques, are appropriate.

D. Assisting the spouse to give small sips of water without assessing swallowing is unsafe. Although the intention is to support hydration, providing fluids to a client with potential dysphagia can result in choking, aspiration, and subsequent respiratory complications. Safety must take precedence over immediate hydration in this scenario.

A. Notify the nurse of a client's readiness for discharge. B. Remove a client's discontinued nasogastric tube. C. Assist clients on the unit with using incentive spirometer devices. D. Irrigate a urinary catheter with normal saline.

Correct Answer is C

Explanation

A. This option is incorrect because determining or confirming a client’s readiness for discharge requires clinical judgment and assessment, which is the responsibility of a licensed nurse (RN or PN). A UAP may observe and report findings, but should not be responsible for recognizing discharge readiness.

B. This option is incorrect because removing a nasogastric tube is an invasive procedure that requires assessment of the client’s condition and potential complications such as aspiration or bleeding. This task must be performed by a licensed nurse, not a UAP.

C. This option is correct because assisting with the use of an incentive spirometer is a routine, non-invasive task that can be safely delegated to a UAP. The RN is responsible for initial teaching and assessment, but once instruction has been provided, the UAP can help reinforce its use and encourage the client to perform deep breathing exercises.

D. This option is incorrect because irrigating a urinary catheter is a sterile procedure that requires nursing knowledge, skill, and assessment for complications such as infection or obstruction. This task must be performed by a licensed nurse.

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The charge nurse in a critical care unit is reviewing client conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit? Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (140 to 180 g/L)]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the UAP?

Correct Answer is C

Explanation

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