A nurse is caring for a group of clients on a medical unit. For which of the following clients should the nurse intervene immediately?
A client who had an appendectomy and has a urine output of 260 mL over 8 hr
A client who is immobile and has had an episode of urinary incontinence
A client who has COPD and an oxygen saturation of 99%
A client who has a concussion and has developed aphasia
The Correct Answer is D
A. A client who had an appendectomy and has a urine output of 260 mL over 8 hr: A urine output of 260 mL over 8 hours is average (around 32.5 mL/hr), and it does not require immediate intervention. It is important to monitor, but there is no acute concern at this time.
B. A client who is immobile and has had an episode of urinary incontinence: While urinary incontinence can lead to skin breakdown and other issues, it is not immediately life-threatening. The nurse should address it with appropriate interventions, but it is not urgent.
C. A client who has COPD and an oxygen saturation of 99%: An oxygen saturation of 99% in a client with COPD is within normal limits. This indicates that the client’s respiratory status is stable and does not require immediate intervention.
D. A client who has a concussion and has developed aphasia: Aphasia after a concussion can indicate a serious complication, such as increased intracranial pressure or a brain injury. This requires immediate intervention to assess the severity of the condition and prevent further neurological damage.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Moderate serosanguineous drainage: Moderate serosanguineous drainage is normal within the first few hours following a total thyroidectomy. It typically decreases as the wound heals, and it does not require immediate intervention unless it becomes excessive or persistent.
B. Hoarseness: Hoarseness can occur after a thyroidectomy due to irritation or injury to the vocal cords during surgery. This is common but should be monitored. It does not necessarily require urgent reporting unless it worsens or is associated with difficulty breathing.
C. Muscle twitching: Muscle twitching, especially around the face, hands, or feet, can be a sign of hypocalcemia, which may occur after a thyroidectomy due to possible damage to the parathyroid glands. This requires immediate reporting to prevent further complications.
D. Neck stiffness: Neck stiffness is a common complaint after thyroid surgery due to muscle strain or positioning during surgery. It is usually not an emergency but should be monitored for worsening symptoms or pain.
Correct Answer is D
Explanation
A. A client who had an appendectomy and has a urine output of 260 mL over 8 hr: A urine output of 260 mL over 8 hours is average (around 32.5 mL/hr), and it does not require immediate intervention. It is important to monitor, but there is no acute concern at this time.
B. A client who is immobile and has had an episode of urinary incontinence: While urinary incontinence can lead to skin breakdown and other issues, it is not immediately life-threatening. The nurse should address it with appropriate interventions, but it is not urgent.
C. A client who has COPD and an oxygen saturation of 99%: An oxygen saturation of 99% in a client with COPD is within normal limits. This indicates that the client’s respiratory status is stable and does not require immediate intervention.
D. A client who has a concussion and has developed aphasia: Aphasia after a concussion can indicate a serious complication, such as increased intracranial pressure or a brain injury. This requires immediate intervention to assess the severity of the condition and prevent further neurological damage.
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