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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Hgb 11.5 g/dL (12 to 16 g/dL): While this hemoglobin level is slightly below normal, it is not an immediate priority compared to other more concerning values. Anemia could be addressed later with appropriate interventions but is not life-threatening in this case.

B. Creatinine 3.2 mg/dL (0.5 to 1.1 mg/dL): A creatinine level of 3.2 mg/dL is significantly elevated and indicates possible kidney dysfunction or acute kidney injury. Gentamicin is known to be nephrotoxic, and this level requires prompt attention to prevent further renal damage.

C. Sodium 146 mEq/L (136 to 145 mEq/L): Sodium levels are only slightly elevated and do not represent an immediate concern unless the client has symptoms of hypernatremia (e.g., confusion, seizures). While monitoring is required, it is not as urgent as the creatinine.

D. WBC count 12,000/mm3 (5,000 to 10,000/mm3): A WBC count of 12,000/mm3 is mildly elevated, which could suggest an infection or inflammation. However, this is not the priority compared to the kidney function, which could be compromised by gentamicin therapy.

A. Dilated appearance of the AV site B. Absence of a bruit C. 2+ left radial pulse D. Presence of a palpable thrill

Correct Answer is B

Explanation

A. Dilated appearance of the AV site: A dilated appearance of the AV site is not necessarily a complication. Some dilation may be expected as the graft matures. However, significant or sudden dilation could indicate an issue, such as stenosis or a developing clot, which should be assessed further.

B. Absence of a bruit: The absence of a bruit over an arteriovenous graft is a sign of a potential complication, such as thrombosis or a blockage in the graft. The bruit indicates proper blood flow through the graft. Its absence suggests a lack of blood flow, which requires immediate attention.

C. 2+ left radial pulse: A 2+ pulse is considered normal and indicates adequate peripheral circulation. It does not suggest a complication related to the AV graft.

D. Presence of a palpable thrill: A palpable thrill is typically a normal finding when assessing an AV graft. It is the vibration felt over the graft site due to blood flow and indicates that the graft is functioning properly.

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A nurse is caring for a group of clients on a medical unit. For which of the following clients should the nurse intervene immediately?

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