Which of the following clients should be considered a priority for immediate assessment and intervention?

A client who has epidural analgesia and weakness in the lower extremities

A client who has diabetes mellitus and an HbA1c of 7.2% (less than 79%).

A client who has sinus arrhythmia and is receiving cardiac monitoring.

A client who has a hip fracture and a new onset of tachypnea.

Answer and Explanation

The Correct Answer is D

A. A client who has epidural analgesia and weakness in the lower extremities: Lower extremity weakness can be a side effect of epidural analgesia. While it requires monitoring, it is typically not immediately life-threatening unless accompanied by other neurological changes.

B. A client who has diabetes mellitus and an HbA1c of 7.2%: An HbA1c of 7.2% indicates slightly above-target blood glucose control. This is a chronic management concern and does not require immediate intervention.

C. A client who has sinus arrhythmia and is receiving cardiac monitoring: Sinus arrhythmia is often a benign, expected finding, particularly in children or young adults. Continuous monitoring is appropriate, but it is not an emergent concern.

D. A client who has a hip fracture and a new onset of tachypnea: New-onset tachypnea in a client with a hip fracture can indicate a serious complication such as pulmonary embolism or fat embolism syndrome. This requires immediate assessment and intervention.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

A. Expected outcome of the procedure: The provider must explain the anticipated results of the colon resection so the client can make an informed decision about proceeding with the surgery.

B. Potential complications: The client should be informed of the risks and possible adverse events associated with the procedure, which is essential for informed consent.

C. Cost of the procedure: Financial information is not required for informed consent. While helpful for planning, it is not part of the medical disclosure required by the provider.

D. Explanation of the procedure: A clear description of the surgical steps allows the client to understand what the procedure entails, which is a fundamental component of informed consent.

E. Possible alternative treatments: The client must be aware of other treatment options, including the choice of no treatment, to make an informed decision regarding surgery.

A. Inform the client she will need to formula feed her newbom until she has received antibiotics for 24 hr. B. Request a prescription for terbutaline from the provider. C. Monitor the height and tone of the client's fundus. D. Instruct the client to wash her hands before and after changing her perineal pad. E. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage. F. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab. G. Initiate contact precautions.

Correct Answer is ["C","D","E","F"]

Explanation

Rationale:

A. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics used to treat postpartum endometritis are safe for breastfeeding. Temporary formula feeding is not routinely required.

B. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to suppress preterm labor, which is not indicated postpartum. It does not treat infection or uterine complications.

C. Monitor the height and tone of the client's fundus: Assessing the uterus for firmness and position helps detect uterine atony or worsening infection. Changes in fundal height or tone can indicate retained products of conception or hemorrhage.

D. Instruct the client to wash her hands before and after changing her perineal pad: Hand hygiene reduces the risk of introducing or spreading bacteria to the uterus or perineal area, which is critical when postpartum infection is present.

E. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Semi-Fowler’s positioning promotes drainage of lochia, decreases uterine congestion, and supports recovery from endometritis by reducing bacterial proliferation in pooled fluid.

F. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: A culture helps identify the causative organism of endometritis, allowing the provider to tailor antibiotic therapy effectively.

G. Initiate contact precautions: Endometritis is not a highly transmissible condition; standard precautions, including hand hygiene, are sufficient unless another communicable infection is identified.

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Which of the following clients should be considered a priority for immediate assessment and intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to witness a client's signature on a consent form for a colon resection. The nurse should recognize that which of the follow information should be provided to the client by the provider before signing the form? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

A nurse reviews the provider prescriptions and reassesses the client. Exhibits The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["C","D","E","F"]

Explanation

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