Which assessment data would warrant immediate intervention by the nurse?
The client with an inguinal hernia care who must void before discharge
The client with an open cholecystectomy who refuses to deep breathe
The client diagnosed with deep vein thrombosis reporting pain on inspiration
The immobile client refusing to turn for the last three hours
The Correct Answer is C
A. While ensuring that a client with an inguinal hernia voids before discharge is important, it does not warrant immediate intervention unless there are signs of urinary retention or other complications.
B. Refusing to deep breathe after an open cholecystectomy can increase the risk of postoperative complications like atelectasis, but it does not require immediate intervention unless there are signs of respiratory distress or infection.
C. Pain on inspiration in a client with deep vein thrombosis (DVT) is a potential sign of pulmonary embolism (PE), a life-threatening complication. Immediate assessment and intervention are critical to prevent further deterioration.
D. Refusing to turn for three hours increases the risk of pressure injuries, but this is not as urgent as the potential for a pulmonary embolism. The nurse should address this issue promptly but not before assessing the client with possible PE.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Fluticasone is an inhaled corticosteroid often used to manage asthma. It does not pose a direct risk to a client with heart failure and asthma, so clarification is not needed for this medication.
B. Amoxicillin is an antibiotic and does not directly affect asthma or heart failure. It is not contraindicated in clients with these conditions, so clarification is not necessary.
C. Isosorbide dinitrate is a nitrate used to treat heart failure by reducing cardiac workload and improving oxygen delivery. It does not affect asthma and does not require clarification.
D. Carvedilol is a beta-blocker that is commonly used to manage heart failure, but it is a non-selective beta-blocker, which can exacerbate asthma symptoms by causing bronchoconstriction. In clients with a history of asthma, beta-1 selective blockers are preferred, so clarification of this order is necessary.
Correct Answer is C
Explanation
A. Assessing the patient’s vital signs is important but is not the first priority during an acute asthma attack. The primary concern is airway patency and breathing effectiveness.
B. Checking the patient’s blood pressure is part of a comprehensive assessment but is not the immediate priority in this scenario. It does not directly address the respiratory distress associated with an asthma attack.
C. Assessing the patient’s lung sounds is the first priority as it provides critical information about the severity of the airway obstruction and the effectiveness of the patient’s breathing. Identifying wheezing, diminished breath sounds, or silent chest (absence of airflow) is essential for immediate intervention.
D. Obtaining a complete medical history is important for long-term management but is not the priority during an acute asthma attack. Immediate assessment and stabilization take precedence.
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