A nurse is participating in interprofessional team meeting for a client. Which of the following information about the client should the nurse include?

The client’s vital signs are checked every 8 hr

The client has developed difficulty ambulating

The client has state-sponsored health insurance

The client's next dressing change is scheduled in 4 hr.

Answer and Explanation

The Correct Answer is B

A) The client’s vital signs are checked every 8 hr: While vital signs are an important aspect of the client's health, this information is routine and doesn't provide new insights that would impact the overall plan of care during an interprofessional team meeting. It’s important to focus on changes in the client’s condition or specific concerns that require collaboration.

B) The client has developed difficulty ambulating: This is critical information to share during the interprofessional team meeting because it may require input from physical therapists, occupational therapists, or other specialists. Difficulty ambulating can indicate a need for reassessment of the client's mobility plan, and other team members need to be informed to develop appropriate interventions.

C) The client has state-sponsored health insurance: While the client’s insurance status is relevant for financial and discharge planning, it is not directly related to the clinical management or care coordination that would be discussed in an interprofessional team meeting. The focus should be on the client’s clinical condition and needs.

D) The client's next dressing change is scheduled in 4 hr: Although the dressing change is important for continuity of care, this is more of a task-related detail rather than critical clinical information that requires interprofessional discussion. The focus in a team meeting should be on the client's progress, challenges, and needs, not just routine care tasks.

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Correct Answer is C

Explanation

A) Wait 1 min between suctioning attempts: The nurse should wait 20 to 30 seconds between suctioning attempts, not a full minute. Waiting too long between attempts can cause the patient unnecessary distress. The goal is to allow for oxygenation and recovery of the airway in between suctioning attempts.

B) Apply intermittent suction for 30 seconds: Suctioning should be limited to 10 to 15 seconds at a time to prevent hypoxia and damage to the mucous membranes. Applying suction for 30 seconds could lead to complications such as hypoxia, mucosal trauma, and increased risk of infection.

C) Insert the catheter 10 cm (4 in.): This is the correct technique. For an adult client, the catheter should be inserted 10 cm (4 inches) into the airway. Inserting the catheter too far can cause trauma to the airway, while inserting it too shallow may not effectively clear secretions.

D) Apply suction while inserting the catheter: Suction should not be applied while inserting the catheter. Suctioning should only be applied while withdrawing the catheter, not while inserting it, to prevent mucosal trauma and to ensure effective clearance of secretions. Suctioning during insertion could damage the airway and increase discomfort for the client.

A. Client report of muscle spasms of the left leg B. One fingerbreadth of space between the cast and the skin C. Diminished pulses on the affected extremity D. Ecchymosis on the inner left thigh

Correct Answer is C

Explanation

A) Client report of muscle spasms of the left leg: Muscle spasms are common in clients with a cast, especially if the muscle is restricted for an extended period. While muscle spasms can be uncomfortable, they are not immediately life-threatening. The nurse should still address the discomfort but it does not take priority over other potential issues like circulation.
B) One fingerbreadth of space between the cast and the skin: A small amount of space between the cast and the skin can be normal and is typically observed in a well-applied cast. However, this finding alone does not indicate an immediate concern unless other signs such as swelling or impaired circulation are noted.

C) Diminished pulses on the affected extremity: Diminished pulses are a priority concern. This may indicate compromised circulation, which can lead to serious complications such as tissue ischemia or compartment syndrome. The nurse should immediately assess the severity of the circulation problem, as any signs of compromised blood flow require prompt intervention to prevent permanent damage or loss of limb function.

D) Ecchymosis on the inner left thigh: Ecchymosis or bruising on the inner thigh can be a normal consequence of trauma or injury related to the reason for the cast. While it is important to monitor for any changes in the condition, ecchymosis itself is not immediately life-threatening or urgent compared to potential circulation issues.

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A nurse is participating in interprofessional team meeting for a client. Which of the following information about the client should the nurse include?

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