Level: Clinical
Difficulty: Medium
Subtopic: Hypoxia and impaired gas exchange
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to hypoxia and impaired gas…
Pathophysiology Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for nursing care related to hypoxia and impaired gas exchange. Assessment data include sudden slurred speech and right-sided weakness began 30 minutes ago. Which intervention best reduces the client's risk of complications?
Question
A. Restrict all movement without individualized assessment.
B. Delay teaching until the day of discharge only.
C. Ignore small changes until they become severe.
D. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
B. Delay teaching until the day of discharge only.
C. Ignore small changes until they become severe.
D. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
Rationale
Correct answer: D. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.