Level: Foundational
Difficulty: Easy
Subtopic: Fluid volume excess and deficit
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for nursing care related to fluid volume exces…
Pathophysiology Physiological Adaptation
Case Study
A 59-year-old client in the intensive care unit is being evaluated for nursing care related to fluid volume excess and deficit. Assessment data include the client reports sudden sharp chest pain and respirations 32/min after surgery. The nurse is evaluating discharge teaching. Which client statement shows correct understanding?
Question
A. "I will call the nurse if I have new or worse symptoms before my follow-up appointment."
B. "I will stop my medications when I feel better."
C. "I do not need to report mild symptoms unless they become unbearable."
D. "The nurse does not need to know about changes unless the provider asks."
B. "I will stop my medications when I feel better."
C. "I do not need to report mild symptoms unless they become unbearable."
D. "The nurse does not need to know about changes unless the provider asks."
Rationale
Correct answer: A. "I will call the nurse if I have new or worse symptoms before my follow-up appointment."
Rationale: Effective teaching includes when to seek help for worsening symptoms. Stopping medications or delaying reports are unsafe.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Effective teaching includes when to seek help for worsening symptoms. Stopping medications or delaying reports are unsafe.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.