Try Naxlex NCLEX-RN (Free-Trial)

Patient Data

Exhibits
Which assessment factors require immediate nursing intervention based on the nurse’s assessment? Select all that apply)

Pain assessment

Temperature

Blood pressure

Oxygen saturation

Edema

Answer and Explanation

Correct Answer : A,B,C

Rationale for Correct Choices:

Pain assessment: The client reports severe pain (8/10) that has persisted for 9 days without relief. Acute, uncontrolled pain can indicate a worsening gout flare or possible complication, requiring immediate nursing intervention to manage pain and prevent functional impairment.
Temperature: The client’s oral temperature is 100.5°F (38.1°C), indicating a low-grade fever. Fever in the context of acute joint pain raises concern for infection, which requires prompt assessment and possible laboratory workup.
Blood pressure: The client’s blood pressure is elevated at 151/87 mm Hg. While not immediately life-threatening, hypertension in combination with acute pain and fever increases cardiovascular risk and can exacerbate comorbidities. Prompt monitoring and intervention are necessary to prevent complications.

Rationale for Incorrect Choices:

Oxygen saturation: At 95% on room air, the client’s oxygenation is within acceptable limits and does not indicate an immediate threat to tissue perfusion.
Edema: Mild (1+) bilateral lower extremity edema is chronic and consistent with underlying comorbidities, such as hypertension or possible venous insufficiency. It does not require immediate intervention in this acute scenario.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is []

Explanation

Rationale for Correct Choices

Urinary Retention: The client has a palpable, full bladder, low urine output despite the urge to void, and a bladder scanner showing 600 mL residual urine. These findings indicate acute urinary retention, a common postoperative complication.
Insert indwelling urinary catheter: An indwelling catheter relieves acute urinary retention, prevents bladder overdistention, and reduces risk of renal damage. Prompt catheterization is often necessary when residual volume is significant.
Assist client to bathroom for voiding: Encouraging normal voiding helps stimulate bladder function and prevents retention from becoming chronic. Assisting the client provides safe positioning and promotes voluntary urination.
Amount of urine output: Monitoring urine output helps assess the effectiveness of interventions and ensures that retention is resolving. Accurate measurement is crucial for postoperative clients.
Residual urine: Reassessing residual urine via bladder scanner or catheterization confirms bladder emptying and helps guide ongoing management to prevent complications like overflow incontinence or infection.

Rationale for Incorrect Choices:

Request prescription for external catheter device: External catheter devices (condom catheters) are generally used for incontinent males or for urinary collection in nonobstructed situations. They do not address underlying urinary retention in a female client and would not relieve bladder distension.
Assist client to bathroom for voiding: Although helping the client to the bathroom may aid functional voiding, the large residual urine volume (600 mL) indicates that this alone will not resolve urinary retention. Physical assistance is insufficient for significant retention.
Increase the IV fluid rate: Increasing IV fluids could worsen urinary retention by adding more volume to the bladder, potentially causing overdistension. Fluid administration should be guided by hydration needs and urine output, not as a treatment for retention.
Overflow Urinary Incontinence: While overflow incontinence can occur secondary to retention, the primary problem is urinary retention itself. Management focuses first on emptying the bladder rather than addressing incontinence.
Functional Urinary Incontinence: Functional incontinence occurs when the bladder is functioning normally, but the client cannot reach the toilet due to physical or cognitive limitations. This client has evidence of true retention, making functional incontinence an incorrect diagnosis.
Urinary tract obstruction: Obstruction can cause retention, but the scenario does not indicate anatomical obstruction, stones, or structural abnormalities. Postoperative retention due to anesthesia is more likely.
Pain medication effects: While analgesics may contribute to urinary retention, monitoring their effect is not a primary indicator of improvement in bladder emptying. Direct assessment of urine output and residual volume is more relevant.
Frequency of voiding: Frequency alone does not indicate effective bladder emptying. The client may void small amounts frequently while retaining large residuals, so residual urine measurement is more informative.
IV fluid intake: Monitoring fluid intake is important for overall hydration but does not directly reflect progress in resolving urinary retention. Output and residual volume are more relevant indicators.

A. Client describes a schedule for antacid use with other prescribed medications. B. Client agrees to participate in a variety of stress reduction techniques. C. Client selects a pattern of small meals alternating with fluid intake. D. Client expresses a willingness to reduce nicotine intake.

Correct Answer is C

Explanation

Rationale:
A. Client describes a schedule for antacid use with other prescribed medications: While antacids may be part of postoperative care, they do not directly address the symptoms of nausea, diarrhea, and diaphoresis that occur after meals following a Billroth II procedure.

B. Client agrees to participate in a variety of stress reduction techniques: Stress management is beneficial for overall health, but it does not specifically target postprandial symptoms related to dumping syndrome.

C. Client selects a pattern of small meals alternating with fluid intake: This outcome directly addresses the management of dumping syndrome, a common complication after Billroth II surgery. Small, frequent meals and separating solids from liquids slow gastric emptying and help prevent postprandial hypotension, nausea, and diarrhea.

D. Client expresses a willingness to reduce nicotine intake: Smoking cessation is important for general healing and gastrointestinal health, but it does not specifically mitigate the acute postprandial symptoms associated with dumping syndrome.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Patient Data Exhibits Which assessment factors require immediate nursing intervention based on the nurse’s assessment? Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Complete the diagram below by indicating the potential condition of this client, actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?

Correct Answer is C

Explanation

A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

Patient Data Exhibits Complete the diagram below by indicating the potential condition of this client, actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

Patient Data

Exhibits
Which assessment factors require immediate nursing intervention based on the nurse’s assessment? Select all that apply)