Level: Foundational
Difficulty: Easy
Subtopic: Inflammation and cellular injury
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to inflammation and cellular…
Pathophysiology Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for nursing care related to inflammation and cellular injury. Assessment data include urine output 15 mL/hr for 2 hours with rising creatinine. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that urine output 15 mL/hr for 2 hours with rising creatinine.
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 urine output 15 mL/hr for 2 hours with rising creatinine.
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.