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 B
Explanation
Choice A Reason: This is not the first priority because it is not a life-threatening condition. The male adolescent may have gastroenteritis or food poisoning, which can cause dehydration and electrolyte imbalance. The nurse should monitor his vital signs and fluid intake, but he can wait for further assessment.
Choice B Reason: This is the first priority because it is a potential surgical emergency. The female client may have appendicitis, which can cause peritonitis and sepsis if left untreated. The nurse should assess her pain level, vital signs, and abdominal signs, and prepare her for diagnostic tests and possible surgery.
Choice C Reason: This is not the first priority because it is a chronic condition that does not require immediate intervention. The elderly client may have intermittent claudication, which is a symptom of peripheral arterial disease. The nurse should educate him on leg care and exercise, but he can wait for further assessment.
Choice D Reason: This is not the first priority because it is a common condition that can be treated with antibiotics. The child may have a bacterial infection, such as bronchitis or pneumonia, which can cause productive cough and fever. The nurse should auscultate his lungs and check his temperature, but he can wait for further assessment.
Correct Answer is A
Explanation
Choice A reason: This client has signs of dehydration and fluid volume deficit, which can lead to shock, a life-threatening condition that occurs when the body's organs are not receiving enough blood flow. The nurse should monitor the client's vital signs, urine output, skin color, and level of consciousness, and report any changes to the physician.
Choice B reason: Initiating enteric precaution procedures is important to prevent the spread of infection, as vomiting and diarrhea may be caused by a contagious pathogen. However, this is not the most important action for the nurse to implement, as it does not address the client's immediate risk of shock.
Choice C reason: Reducing light, noise and temperature may help the client feel more comfortable and reduce nausea, but it is not the most important action for the nurse to implement, as it does not address the client's fluid volume deficit and potential shock.
Choice D reason: Encouraging electrolyte supplements may help replenish the electrolytes lost through vomiting and diarrhea, but it is not the most important action for the nurse to implement, as it may not be enough to restore the fluid balance and prevent shock. The client may need intravenous fluids and medications to correct the dehydration and hypotension.
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