Which client requires the most immediate intervention by the nurse?

An older adult receiving enteral feedings via feeding tube who has a temperature of 100.6°F (38.1°C).

A client with acute kidney injury who is somnolent and does not respond to verbal commands.

A young adult who experienced heat stroke and is receiving a normal saline intravenous (IV) fluid bolus.

A pregnant client with hyperemesis gravidarum who is receiving an infusion of Ringer's Lactate.

Answer and Explanation

The Correct Answer is B

A)   This client has a mild fever, which may indicate an infection or inflammation. This is a potential complication of enteral feedings, but it is not the most urgent situation. The nurse should monitor the client's vital signs, assess the feeding tube site, and notify the provider if the fever persists or worsens.
B)   This client has signs of uremic encephalopathy, which is a life-threatening condition caused by the accumulation of toxins in the brain due to impaired renal function. The nurse should intervene immediately to prevent further
neurological damage and possible coma or death. The nurse should assess the client's level of consciousness, check the blood pressure and urine output, and prepare to administer dialysis or other treatments as ordered by the provider.
C)   This client has heat stroke, which is a serious condition that can lead to dehydration, electrolyte imbalance, and organ damage. However, the client is receiving a normal saline IV fluid bolus, which is an appropriate intervention to restore fluid volume and correct sodium levels. The nurse should continue to monitor the client's vital signs, skin
temperature, and urine output, and watch for signs of fluid overload or cerebral edema.
D)   This client has hyperemesis gravidarum, which is a severe form of nausea and vomiting during pregnancy that can lead to dehydration, malnutrition, and electrolyte imbalance. However, the client is receiving an infusion of Ringer's Lactate, which is an isotonic solution that can replenish fluid and electrolyte losses. The nurse should continue to monitor the client's vital signs, weight, and intake and output, and administer antiemetics or other medications as ordered by the provider.

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Correct Answer is D

Explanation

Choice A Reason: This assignment does not require immediate follow-up action by the charge nurse because a practical nurse can transport a stable postoperative client to another unit and report any changes or concerns to the primary nurse.

Choice B Reason: This assignment does not require immediate follow-up action by the charge nurse because a practical nurse can monitor the blood pressure of a client with hypertension and administer antihypertensive medications as prescribed and delegated by the primary nurse.

Choice C Reason: This assignment does not require immediate follow-up action by the charge nurse because a graduate nurse can obtain a unit of packed red blood cells from the blood bank and verify the compatibility and identification with another registered nurse before transfusing it to the client.

Choice D Reason: This is the correct answer because checking a client for fecal impaction is beyond the scope of practice of unlicensed assistive personnel. It involves inserting a finger into the rectum and assessing for hard stool, which can cause injury or infection to the client. The charge nurse should intervene and assign this task to a registered nurse or a practical nurse.

A. The brain natriuretic peptide (BNP) assay for a client with shortness of breath after a myocardial infarction (MI) increases to 1000 pg/mL (1000 ng/L). B. The international normalized ratio (INR) for a client who is receiving warfarin therapy increases to 2.5. C. The serum glucose level for a client receiving corticosteroids increases to 150 mg/dL (8.3 mmol/L). D. The potassium level for a client scheduled for renal dialysis increases to 5 mEq/L(5 mmol/L).

Correct Answer is A

Explanation

Choice A Reason: This client has a very high BNP level, which indicates severe heart failure and fluid overload. The nurse should follow up with this client first, as they may need urgent interventions such as oxygen therapy, diuretics, and vasodilators.

Choice B Reason: This client has an INR within the therapeutic range for warfarin therapy, which is usually between 2 and 3. The nurse should monitor this client for signs of bleeding or clotting, but they do not require immediate follow-up.

Choice C Reason: This client has a mildly elevated glucose level, which may be caused by the corticosteroids that

increase blood sugar. The nurse should check the client's blood glucose regularly and administer insulin as ordered, but they do not require immediate follow-up.

Choice D Reason: This client has a normal potassium level, which is within the reference range of 3.5 to 5 mEq/L. The nurse should ensure that the client is ready for dialysis and avoid foods high in potassium, but they do not require immediate follow-up.

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Which client requires the most immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

The nurse manager decides to report a staff nurse to the Peer Review Committee (PRC). Which activity merits this action?

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In assigning client care to a nurse and a practical nurse (PN), it is most important to assign which client to the nurse?

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