Level: Foundational
Difficulty: Easy
Subtopic: Fluid volume excess and deficit
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to fluid volume excess and d…
Pathophysiology Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for nursing care related to fluid volume excess and deficit. 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. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that hemoglobin 6.8 g/dL with pallor and hypotension 90/55 mm Hg.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that hemoglobin 6.8 g/dL with pallor and hypotension 90/55 mm Hg.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. 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.