Level: Foundational
Difficulty: Easy
Subtopic: Respiratory gas exchange
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to respiratory gas exchange….
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for nursing care related to respiratory gas exchange. Assessment data include a family member reports the client seems confused since this morning. 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. Routine data unchanged from the prior assessment.
D. The new finding that a family member reports the client seems confused since this morning.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that a family member reports the client seems confused since this morning.
Rationale
Correct answer: D. The new finding that a family member reports the client seems confused since this morning.
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.