Which assessment data would warrant immediate intervention by the nurse?

The client with an inguinal hernia care who must void before discharge

The client with an open cholecystectomy who refuses to deep breathe

The client diagnosed with deep vein thrombosis reporting pain on inspiration

The immobile client refusing to turn for the last three hours

Answer and Explanation

The Correct Answer is C

A. While ensuring that a client with an inguinal hernia voids before discharge is important, it does not warrant immediate intervention unless there are signs of urinary retention or other complications.

B. Refusing to deep breathe after an open cholecystectomy can increase the risk of postoperative complications like atelectasis, but it does not require immediate intervention unless there are signs of respiratory distress or infection.

C. Pain on inspiration in a client with deep vein thrombosis (DVT) is a potential sign of pulmonary embolism (PE), a life-threatening complication. Immediate assessment and intervention are critical to prevent further deterioration.

D. Refusing to turn for three hours increases the risk of pressure injuries, but this is not as urgent as the potential for a pulmonary embolism. The nurse should address this issue promptly but not before assessing the client with possible PE.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Explanation

A. Diarrhea: Not relevant to the client's condition of impaired mobility and recent hip fracture.

B. Hypocalcemia: Not directly related to the client's current condition and symptoms.

C. Pulmonary embolism: The client is at risk due to limited mobility and signs of deep vein thrombosis.

D. Deep vein thrombosis: The client has symptoms such as a warm, reddened area on the calf, indicating a potential DVT.

E. Hypertension: The client's blood pressure is within normal limits, so this is not a primary concern.

A. Check the chest tube for kinks or obstructions. B. Notify the healthcare provider immediately. C. Increase the suction pressure on the chest tube. D. Continue to monitor the client and reassess in 1 hour.

Correct Answer is A

Explanation

A. If there is no fluctuation in the water seal compartment, the first action should be to check for kinks, obstructions, or other issues in the tubing that might block air or fluid movement. Fluctuation (tidaling) is expected during respiration, and its absence may indicate a problem with the system or that the lung has fully re-expanded.

B. Notifying the healthcare provider immediately is not the first step. The nurse should first assess the chest tube system to determine if there is an issue that can be resolved without medical intervention.

C. Increasing the suction pressure on the chest tube is not appropriate without first identifying the cause of the lack of fluctuation. Adjusting suction may not address the underlying problem.

D. Continuing to monitor and reassess in 1 hour delays addressing the potential issue. Immediate assessment of the chest tube system is necessary to ensure proper functioning.

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Which assessment data would warrant immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing impaired mobility. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing dropdown and dropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Explanation

A client had a right-sided chest tube inserted two hours ago for pneumothorax. Which action should the nurse implement if there is no fluctuation in the water seal compartment?

Correct Answer is A

Explanation

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