A nurse is assisting in the care of a newly admitted client.

Exhibits

Which of the following findings should the nurse report immediately to the provider? Select all that apply.

Explanation

C. The client has developed difficulty ambulating

The information about the client's difficulty ambulating is relevant to the interprofessional team because it may require input and collaboration from various healthcare professionals to address and manage the client's mobility issues. This information helps the team understand the client's current condition and plan appropriate interventions.

The client having state-sponsored health insurance in (option A) is incorrect because it is not directly relevant to the interprofessional team meeting unless it specifically impacts the client's healthcare options, resources, or access to care. However, it may be important to know for insurance-related discussions or considerations, depending on the purpose of the team meeting.

The client's next dressing change being scheduled in 4 hours in (option B) is incorrect because it is important information for the nurse's own clinical responsibilities, but it may not be directly relevant to the broader interprofessional team meeting unless it has implications for the client's overall care plan or requires input from other team members.

The frequency of the client's vital sign checks being every 8 hours in (option D) is incorrect because it is important for the nurse's routine monitoring and care, but it may not be the primary focus of the interprofessional team meeting unless there are specific concerns or changes in the client's vital signs that need to be addressed collaboratively.

In summary, the nurse should include information about the client's difficulty ambulating during the interprofessional team meeting, as it helps inform the team's discussions, interventions, and plans regarding the client's mobility and potential impact on their overall care.

Waiting 1 minute between suctioning attempts allows the client to recover and ensures that the procedure is not overly invasive. It also helps to prevent the client from becoming hypoxic.

The distance that the nasopharyngeal catheter should be inserted varies from person to person and therefore 10 cm is not standard.

During nasopharyngeal suctioning, the nurse should apply suction intermittently while withdrawing the catheter, not during insertion. Applying suction during insertion can cause tissue damage and increase the risk of trauma.

The nurse should also apply intermittent suction for no longer than 15 seconds to prevent hypoxia and damage to the mucosal lining. Suctioning for an extended period can cause discomfort and harm to the client.