A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?
Erythema on pressure points.
Lower extremity pulse strength of 2+.
Fluid intake less than 3,000 mL per day.
One bowel movement every other day.
The Correct Answer is A
Choice A rationale
Erythema on pressure points is a primary indicator of stage 1 pressure injuries, signaling that the skin and underlying tissues are undergoing localized hypoxia due to compressed blood vessels. In an immobile client, redness that does not blanch indicates that microcirculation is compromised. The nurse must intervene immediately by implementing a repositioning schedule to restore blood flow and prevent the progression to full-thickness tissue necrosis.
Choice B rationale
A pulse strength of 2+ is considered a normal finding in an adult, indicating a brisk and palpable arterial flow. While immobility increases the risk of deep vein thrombosis due to venous stasis, a 2+ pulse suggests that the peripheral arterial circulation is currently adequate. The nurse should continue to monitor for other signs of vascular issues, but this specific finding does not require an immediate corrective intervention.
Choice C rationale
Although high fluid intake is encouraged to prevent renal calculi and constipation in immobile clients, an intake of less than 3,000 mL per day is not necessarily an emergency. Many adults maintain adequate hydration with 2,000 to 2,500 mL daily. Unless the client shows signs of dehydration, such as dark urine or poor skin turgor, this finding is less urgent than the signs of localized tissue ischemia seen in erythema.
Choice D rationale
Having a bowel movement every other day is often within the normal range for many healthy adults. While immobility significantly decreases gastrointestinal motility and increases the risk of constipation, a frequency of every 48 hours is not inherently pathological. The nurse should assess for stool consistency and abdominal distension, but a specific intervention is not required solely based on this frequency if the client remains comfortable.
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Correct Answer is D
Explanation
Choice A rationale
Phosphate levels are generally not the primary concern when administering loop diuretics like furosemide. While diuretics can affect various electrolytes, the most significant life-threatening imbalances caused by furosemide involve potassium and sodium. Normal serum phosphate ranges from 3.0 to 4.5 mg/dL. While it is important to monitor overall metabolic status in heart failure patients, phosphate does not have the same immediate impact on cardiac rhythm and muscle function as potassium does during diuretic therapy.
Choice B rationale
Carbon dioxide levels in a metabolic panel reflect the bicarbonate concentration and the acid-base balance of the blood. While loop diuretics can cause metabolic alkalosis, which would increase these levels, it is not the most critical parameter to check before a single dose. Normal venous carbon dioxide levels range from 23 to 30 mEq/L. The priority is to assess for electrolyte deficiencies that could cause immediate cardiac complications, making potassium a more vital laboratory value to review.
Choice C rationale
Bicarbonate levels are an indicator of the body's acid-base status. Furosemide can lead to contraction alkalosis, causing an increase in bicarbonate levels over time. Normal bicarbonate levels range from 22 to 28 mEq/L. While monitoring for alkalosis is part of long-term care for clients on diuretics, it is not the priority assessment before drug administration. The nurse must prioritize electrolytes that directly influence heart rate and rhythm in the context of heart failure and loop diuretic use.
Choice D rationale
Furosemide is a loop diuretic that inhibits the reabsorption of sodium, chloride, and water in the ascending limb of the loop of Henle, leading to increased excretion of potassium. Normal serum potassium levels are 3.5 to 5.0 mEq/L. Administering furosemide to a client with hypokalemia can lead to life-threatening cardiac arrhythmias. Because heart failure patients often take other medications like digoxin, low potassium significantly increases the risk of toxicity and must be verified before administration.
Correct Answer is A
Explanation
Choice A rationale
In the PQRST pain assessment mnemonic, the letter Q stands for Quality. This component focuses on the nature or character of the pain. By asking the client to describe what the pain feels like, the nurse is gathering descriptors such as sharp, dull, stabbing, burning, or crushing. This qualitative data helps healthcare providers differentiate between types of pain, such as visceral, somatic, or neuropathic, which is essential for determining the underlying pathological cause.
Choice B rationale
Precipitating cause, represented by the letter P in the mnemonic, refers to what triggers the pain or what the client was doing when it started. It also includes factors that provoke or palliate the sensation. Asking the client what the pain feels like does not address the onset or the activities that aggravate the condition. Instead, it focuses purely on the sensory description rather than the external or internal events that lead to the pain's occurrence.
Choice C rationale
Severity is represented by the letter S and involves quantifying the intensity of the pain, usually on a scale of 0 to 10. While describing the sensation is important, it does not provide a numerical or comparative measurement of how much it hurts. Severity assessment helps in evaluating the effectiveness of interventions and the urgency of the situation, whereas asking for a description of the feeling specifically targets the qualitative aspect of the client's experience.
Choice D rationale
Region or Radiation, represented by the letter R, identifies the specific anatomical location of the pain and whether it travels to other parts of the body. Asking a client to describe the feeling of the pain provides information about the type of sensation but does not clarify where the pain is located or its path of movement. To assess the region, the nurse would ask the client to point to the area where they feel discomfort.
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