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 B

Explanation

A. Atropine is used to treat bradycardia and is not indicated for pulmonary embolism. It would not be the first choice in managing this condition.

B. Heparin is an anticoagulant that helps prevent further clot formation in the case of a pulmonary embolism. It is typically administered to stabilize the patient and reduce the risk of further embolic events.

C. Dexamethasone is a corticosteroid used to treat inflammation and is not typically used to treat pulmonary embolism. It is not the first-line treatment for this condition.

D. Furosemide is a diuretic used to manage fluid retention and is not directly indicated for pulmonary embolism. It may be used in cases of heart failure or pulmonary edema, but it is not the primary treatment for a pulmonary embolism.

A. Obtain an arterial blood gas and order a portable chest x-ray. B. Instruct the UAP to keep the client on strict bed rest. C. Assess the client for dyspnea and altered mental status. D. Contact the healthcare provider for a ventilation and perfusion scan.

Correct Answer is C

Explanation

A. Obtaining an arterial blood gas and ordering a chest x-ray may be necessary to evaluate the client further, but the nurse must first assess the client to determine the presence of clinical signs of fat embolism syndrome (FES), such as respiratory distress or neurological changes.

B. Keeping the client on strict bed rest may help reduce the risk of further complications, but it is not the first priority. Immediate assessment of the client’s condition is necessary to identify signs of fat embolism syndrome.

C. Assessing the client for dyspnea and altered mental status is the first priority because these symptoms are early indicators of fat embolism syndrome. Early recognition and intervention are critical in preventing further complications.

D. Contacting the healthcare provider for a ventilation and perfusion scan may be appropriate after assessing the client, but it is not the first action. Immediate assessment is essential to determine the urgency of the situation.

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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 has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

Correct Answer is B

Explanation

Unlicensed assistive personnel (UAP) reports a client diagnosed with a fractured femur has "fatty globules" floating in the urinal. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

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