Level: Foundational
Difficulty: Easy
Subtopic: Respiratory disorders
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for pneumonia with increased work of breathing. Asses…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for pneumonia with increased work of breathing. Assessment data include hemoglobin 6.8 g/dL with pallor and hypotension 90/55 mm Hg. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that hemoglobin 6.8 g/dL with pallor and hypotension 90/55 mm Hg.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: A. The new finding that hemoglobin 6.8 g/dL with pallor and hypotension 90/55 mm Hg.
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.