Level: Advanced
Difficulty: Hard
Subtopic: Oxidation and cellular energy
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to oxidation and cellular en…
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 oxidation and cellular energy. Assessment data include the nurse notes an unexpected finding during routine assessment. 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 the nurse notes an unexpected finding during routine assessment.
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 the nurse notes an unexpected finding during routine assessment.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that the nurse notes an unexpected finding during routine assessment.
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.