Level: Clinical
Difficulty: Medium
Subtopic: Gastrointestinal digestion and absorption
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to gastrointestinal digestio…
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 gastrointestinal digestion and absorption. Assessment data include laboratory results return outside the expected range for this condition. 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 laboratory results return outside the expected range for this condition.
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 laboratory results return outside the expected range for this condition.
Rationale
Correct answer: D. The new finding that laboratory results return outside the expected range for this condition.
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.