Patient Data

Based on the client’s assessment findings at 1800, which of the following findings require immediate nursing intervention prior to transfer to the intermediate care unit? Select all that apply.

New-onset agitation

Slurred speech

Disorientation to place and events

Pain rating of 4 on a 0 to 10 scale

History of recent exploratory laparotomy

Stable vital signs within expected ranges

Answer and Explanation

Correct Answer : A,B,C

Rationale:
A. New-onset agitation: Acute agitation in a previously alert and oriented postoperative trauma client raises concern for neurologic compromise, hypoxia, intracranial injury, or evolving delirium. Sudden mental status changes are never expected findings and require immediate assessment before transfer. Early recognition is critical to prevent deterioration.

B. Slurred speech: Slurred speech suggests possible neurologic dysfunction involving cerebral perfusion, cranial nerves, or central nervous system injury. In the context of recent trauma, this finding raises concern for delayed intracranial bleeding or metabolic disturbance. This represents a time-sensitive neurologic red flag.

C. Disorientation to place and events: Acute disorientation indicates an alteration in cognitive function and may reflect delirium, hypoxia, infection, or neurologic injury. A sudden loss of orientation after a period of normal mentation is abnormal and requires prompt investigation. Transfer should be delayed until the cause is identified.

D. Pain rating of 4 on a 0 to 10 scale: A pain level of 4 is mild to moderate and expected following abdominal surgery. The pain was appropriately treated earlier with ibuprofen and does not represent an acute change. This finding does not require immediate intervention prior to transfer.

E. History of recent exploratory laparotomy: A recent laparotomy is a known and stable part of the client’s medical history. The abdominal assessment shows normal postoperative findings with bowel sounds present and a dry, intact dressing. This alone does not explain the acute neurologic changes.

F. Stable vital signs within expected ranges: The client’s vital signs remain within normal limits and show no evidence of hemodynamic instability. Stable vital signs do not exclude serious neurologic pathology. Neurologic deterioration can occur despite normal vital signs and must be prioritized.

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Correct Answer is ["A","C","D","E"]

Explanation

Rationale:
A. Monitor ETT markings between 22 and 26 cm at teeth line: Proper placement is often estimated using standard depth markings on the ETT. Securing the tube at an appropriate depth ensures it is in the trachea rather than the esophagus, reducing the risk of hypoxia or lung injury.

B. Check for capillary refill of 3 seconds or less: Capillary refill assesses peripheral perfusion, not airway placement. It does not provide any information regarding correct ETT positioning or ventilation effectiveness.

C. Auscultate for presence of bilateral breath sounds: Listening to breath sounds in both lungs confirms that the tube is in the trachea and not selectively intubating one bronchus. Bilateral sounds indicate effective ventilation and proper tube placement.

D. Obtain a portable chest x-ray to verify ETT location: Chest radiography is the definitive method to confirm correct ETT placement in the trachea and its depth above the carina. This is standard practice after intubation in an emergency setting.

E. Assess for symmetrical chest movement: Observing equal chest rise and fall during ventilation indicates the ETT is correctly positioned in the trachea and that both lungs are being ventilated. Asymmetry may suggest endobronchial intubation or pneumothorax.

A. Measure abdominal girth. B. Assess perineal area. C. Observe insertion site. D. Palpate flank area.

Correct Answer is C

Explanation

Rationale:
A. Measure abdominal girth: Abdominal girth assessment is more relevant for monitoring ascites or abdominal distention, not for evaluating a suprapubic catheter. It does not provide information about catheter function or complications.

B. Assess perineal area: While perineal skin integrity is important, a suprapubic catheter bypasses the urethra, making perineal assessment less directly related to catheter care.

C. Observe insertion site: Inspecting the suprapubic catheter insertion site is essential to detect signs of infection, leakage, or skin breakdown. Proper site monitoring ensures early identification of complications and maintains catheter patency.

D. Palpate flank area: Flank palpation can detect kidney tenderness, which may indicate infection, but this is secondary to direct inspection of the catheter site. Immediate assessment focuses on the insertion site for safety and infection prevention.

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Patient Data Based on the client’s assessment findings at 1800, which of the following findings require immediate nursing intervention prior to transfer to the intermediate care unit? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is C

Explanation

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Patient Data

Based on the client’s assessment findings at 1800, which of the following findings require immediate nursing intervention prior to transfer to the intermediate care unit? Select all that apply.