Level: Foundational
Difficulty: Easy
Subtopic: Electrolyte charge and movement
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to electrolyte charge and mo…
Chemistry or biochemistry basics Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for nursing care related to electrolyte charge and movement. Assessment data include laboratory results return outside the expected range for this condition. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that laboratory results return outside the expected range for this condition.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: A. 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.