Level: Foundational
Difficulty: Easy
Subtopic: Pharmacokinetics
NCLEX: A 55-year-old client in postanesthesia care is being evaluated for a newly prescribed medication regimen. Assessm…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 55-year-old client in postanesthesia care is being evaluated for a newly prescribed medication regimen. Assessment data include bleeding from the IV site and platelets below the ordered threshold. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that bleeding from the IV site and platelets below the ordered threshold.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that bleeding from the IV site and platelets below the ordered threshold.
Rationale
Correct answer: D. The new finding that bleeding from the IV site and platelets below the ordered threshold.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.