A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist’s notes.

The correct answer is choice A. A client who has a hip fracture and a new onset of tachypnea.

This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention.

Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism.

The nurse should assess this client first and notify the provider.

Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is wellcontrolled and does not need urgent attention.

The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.

Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.

The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A. Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.

Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.

The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.

The correct answer is choice A. A client who has a hip fracture and a new onset of tachypnea.

This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention.

Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism.

The nurse should assess this client first and notify the provider.

Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is wellcontrolled and does not need urgent attention.

The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.

Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.

The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A. Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.

Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.

The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.

The correct answer is d. Evaluate functioning of the suction device.

Choice D rationale:

• Prompt assessment of the suction device is crucial to determine if it's functioning properly.If the suction is inadequate,it can lead to gastric contents accumulating and potentially causing vomiting.
• Assessing the suction device first allows for timely interventionif it's not working correctly,preventing further complications and discomfort for the client.

Choice A rationale:

• Replacing the NG tube might be necessary if it's dislodged or blocked, but it shouldn't be the immediate action.
• Evaluating the suction device first can help determine if the NG tube itself is the issue or if the problem lies with the suction.

Choice B rationale:

• Providing oral hygiene care is important for comfort and to prevent aspiration, but it's not the priority intervention in this situation.
• Addressing the cause of the vomiting, which could be related to suction malfunction, takes precedence.

Choice C rationale:

• Administering an antiemetic might be helpful to control nausea and vomiting, but it doesn't address the underlying cause.
• Evaluating the suction device first is essential to ensure proper gastric decompression and prevent further vomiting episodes.