The charge nurse of a critical care unit must transfer a client to a general unit to make a bed available for an incoming trauma client. Based on the information provided, which client is best for the nurse to recommend for transfer to the general unit?
Subtotal thyroidectomy performed one hour ago, receiving a unit of packed red blood cells.
Combined partial and full-thickness burns on the anterior chest three days ago. O2 saturation is 92%.
Renal transplant yesterday, complaining of flank pain and who states, "it's hot in here."
Nephrotic syndrome diagnosed 2 days ago, decreased serum protein level and mild edema.
The Correct Answer is D
Choice A Reason: A subtotal thyroidectomy is a major surgery that involves the removal of part of the thyroid gland. The client may have complications such as bleeding, infection, hypocalcemia, or vocal cord damage. The client also needs close monitoring of vital signs, blood transfusion, and airway patency. This client is not stable enough to be transferred to a general unit.
Choice B Reason: A combined partial and full-thickness burn is a serious injury that involves damage to the epidermis, dermis, and underlying tissues. The client may have complications such as infection, fluid loss, hypovolemia, shock, or respiratory distress. The client also needs wound care, pain management, fluid replacement, and oxygen therapy. This client is not stable enough to be transferred to a general unit.
Choice C Reason: A renal transplant is a major surgery that involves the replacement of a diseased kidney with a healthy one from a donor. The client may have complications such as rejection, infection, bleeding, thrombosis, or urinary obstruction. The client also needs immunosuppressive therapy, anti-infective therapy, fluid and electrolyte balance, and pain management. This client is not stable enough to be transferred to a general unit.
Choice D Reason: Nephrotic syndrome is a kidney disorder that causes excessive protein loss in the urine, leading to low serum protein levels and edema. The client may have complications such as infection, thromboembolism, or malnutrition. The client needs diuretic therapy, protein replacement, dietary modification, and infection prevention. This client is relatively stable and can be transferred to a general unit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is not the best action because it does not address the conflict between the client and the healthcare provider. The nurse should advocate for the client's wishes and seek a resolution that respects them.
Choice B Reason: This is not an appropriate action because it disregards the client's request and may give false hope. The nurse should respect the client's autonomy and dignity.
Choice C Reason: This is not a sufficient action because it does not ensure that the healthcare provider will comply with the client's request. The nurse should also involve other resources to help resolve the ethical dilemma.
Choice D Reason: This is the best action because it involves an impartial group of experts who can help mediate the situation and protect the client's rights. The nurse should seek ethical consultation when there is a disagreement about end-of-life decisions.
Correct Answer is ["B","C"]
Explanation
Choice A Reason: Identifying locations of skin lesions on a newly admitted client is a nursing assessment that requires clinical judgment and cannot be delegated to the UAP.
Choice B Reason: Emptying the ostomy bag for a client with a temporary colostomy is a routine task that does not require clinical judgment and can be delegated to the UAP.
Choice C Reason: Providing a complete bed bath for a comatose client is a routine task that does not require clinical judgment and can be delegated to the UAP.
Choice D Reason: Performing foot care including toenail trimming and heel care is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP. The UAP may cause injury or infection to the client's feet, especially if the client has diabetes or peripheral vascular disease.
Choice E Reason: Giving mouth care to an elderly client who has a tracheostomy is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP. The UAP may cause trauma or aspiration to the client's trachea, especially if the client has poor oral hygiene or respiratory secretions.
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