Nokea
A hospital is initiating its emergency disaster plan following a mass casualty incident. Which client should the nurse recommend for discharge in preparation for the incoming clients?
- A. A client with type 1 diabetes admitted for new-onset diabetic ketoacidosis and is receiving intravenous insulin
- B. A client with atrial fibrillation admitted 2 days ago, now on oral anticoagulants and in normal sinus rhythm
- C. A client admitted with community-acquired pneumonia requiring oxygen at 3 L/min via nasal cannula
- D. A client admitted with a tibial fracture 6 hours ago, who is post-operative with a cast and stable vital signs
Correct Answer: B
Rationale: The client with atrial fibrillation, now stable on oral anticoagulants (B), is the most suitable for discharge to free beds. Diabetic ketoacidosis (A), pneumonia with oxygen (C), and recent post-operative fracture (D) require ongoing hospital care.
You may also like to solve these questions
Which of the following is the first nursing action for a patient experiencing dyspnea?
- A. Remove pillows from under the patient's head
- B. Elevate the head of the bed
- C. Elevate the foot of the bed
- D. Take the patient's blood pressure
Correct Answer: B
Rationale: Elevating the head of the bed (B) is the first action for dyspnea to improve lung expansion and ease breathing. Removing pillows (A) may worsen discomfort, elevating the foot (C) is irrelevant, and taking blood pressure (D) is secondary.
The nurse is caring for the following assigned clients. The nurse should initially follow-up with the client who
- A. thirty minutes overdue to be ambulated in the hallway.
- B. refusing to eat their meal following an injection of glargine insulin.
- C. scheduled for discharge in three hours and needs transportation.
- D. requesting diphenhydramine after starting an intravenous antibiotic.
Correct Answer: B
Rationale: Refusing to eat after glargine insulin (B) risks hypoglycemia, requiring immediate follow-up to ensure glucose stability. Overdue ambulation (A), discharge planning (C), and diphenhydramine request (D) are less urgent than preventing a metabolic emergency.
The nurse has completed medication administration to assigned clients. The nurse should initially follow up on the client who received prescribed
- A. mirtazapine and reports sleepiness.
- B. citalopram and reports nausea.
- C. fluphenazine and reports fever.
- D. clonidine and reports dizziness while rolling over in bed.
Correct Answer: C
Rationale: Fever after fluphenazine (C) suggests neuroleptic malignant syndrome, a life-threatening emergency requiring immediate follow-up. Sleepiness with mirtazapine (A), nausea with citalopram (B), and dizziness with clonidine (D) are expected side effects and less urgent.
A client has refused a prescribed injection of subcutaneous heparin. Which initial action should the nurse take?
- A. Document the refusal
- B. Notify the primary healthcare provider (PHCP)
- C. Review the client's most recent platelet count
- D. Inquire with the client about the refusal
Correct Answer: D
Rationale: Inquiring about the refusal (D) allows the nurse to understand the client’s concerns, provide education, and address barriers, promoting informed decision-making. Documenting (A) and notifying the provider (B) are secondary steps, and reviewing platelet count (C) is irrelevant without addressing the refusal first.
The nurse is caring for assigned clients. After administering prescribed medications, the nurse should immediately intervene if the client reports
- A. nausea during an infusion of amphotericin B.
- B. palpitations after receiving rapid-acting insulin.
- C. drowsiness after receiving fentanyl.
- D. itching in the perineal area while receiving intravenous dexamethasone.
Correct Answer: B
Rationale: Palpitations after rapid-acting insulin (B) suggest hypoglycemia or an adverse reaction, requiring immediate intervention to assess and stabilize. Nausea with amphotericin B (A), drowsiness with fentanyl (C), and itching with dexamethasone (D) are expected side effects and less urgent.