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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is ["A","C","D"]
Explanation
A. Decreased PaO2 <60mmHg: A hallmark of fat embolism syndrome (FES) is hypoxemia, which results in a PaO2 less than 60 mmHg. This is a key indicator of the severity of respiratory compromise in FES and ARDS.
B. PaO2 greater than 80mmHg: This would not be consistent with FES. Fat embolism often causes significant hypoxemia, and PaO2 greater than 80 mmHg would indicate adequate oxygenation.
C. Decreased platelet count and hematocrit levels: In fat embolism syndrome, there is often a decrease in platelet count and hematocrit due to disseminated intravascular coagulation (DIC), which can occur as a complication of fat embolism.
D. Changes in ST segment and T-wave: Electrocardiographic changes, including changes in ST segment and T-wave, are commonly seen in fat embolism syndrome due to myocardial injury, hypoxemia, or shock.
E. PaCO2 40mmHg: A PaCO2 of 40 mmHg is within normal limits and does not indicate any significant respiratory distress or abnormality that would be expected in fat embolism syndrome.
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