Which client assessment should a nurse immediately report to the health care provider?
Report of joint pain by a client who recently started taking arthritis medication.
Report of decreased appetite and difficulty sleeping in a recently widowed client.
Weight loss of two pounds in a client admitted in congestive heart failure.
Diminished breath sounds in a client admitted with pneumonia.
The Correct Answer is D
This is because diminished breath sounds indicate poor oxygenation and ventilation, which can lead to respiratory failure and hypoxia. The healthcare provider should be notified immediately to assess the client and provide appropriate interventions.
Choice A is wrong because joint pain is a common side effect of some arthritis medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs). It does not require immediate attention unless it is severe or accompanied by other symptoms, such as swelling, redness, or fever.
Choice B is wrong because decreased appetite and difficulty sleeping are normal responses to grief and loss. They do not indicate a medical emergency, but rather a need for emotional support and counseling.
Choice C is wrong because a weight loss of two pounds in a client admitted with congestive heart failure is a positive sign that indicates fluid removal and improved cardiac function. It does not require immediate reporting, but rather ongoing monitoring and evaluation.
Normal ranges for vital signs are as follows :
- Blood pressure: 90/60 mm Hg to 120/80 mm Hg
- Breathing: 12 to 18 breaths per minute
- Pulse: 60 to 100 beats per minute
- Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client received a dose of clopidogrel at 2200. Clopidogrel is an antiplatelet drug that increases the risk of bleeding during and after a liver biopsy. The healthcare provider should be informed of this medication and decide whether to postpone the biopsy or administer reversal agents.
Choice A is wrong because being NPO since 2300 is a standard preparation for a liver biopsy.
Choice B is wrong because pain in the left lower quadrant and constipation are not related to the liver biopsy and do not pose an immediate risk.
Choice D is wrong because having an allergy is not relevant to the liver biopsy unless it is an allergy to the local anesthetic or contrast agent used.
Correct Answer is A
Explanation
The nurse should first assess the client’s bladder for distention by palpating the lower abdomen between the symphysis pubis and the umbilicus.
This can indicate urinary retention, which is a common postoperative complication. The nurse should also measure the bladder volume using a bladder scanner if available.
Choice B. Inform the surgeon that the client’s status is wrong because the nurse should first assess the client before notifying the surgeon.
The surgeon may order interventions based on the assessment findings.
Choice C. Increasing the client’s fluid intake is wrong because increasing fluid intake may worsen bladder distention and discomfort.
The nurse should encourage fluid intake only after ensuring adequate urinary output.
Choice D. Administering pain medication is wrong because pain medication may not be indicated for urinary retention.
Pain medication may also cause urinary retention by relaxing the bladder muscles and impairing the micturition reflex.
Normal urine output is about 30 mL per hour or 240 mL in eight hours.
The nurse should monitor the client’s intake and output and report any signs of urinary retention to the surgeon.
Urinary retention can lead to infection, bladder damage, and renal impairment if not treated promptly.
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