Level: Foundational
Difficulty: Easy
Subtopic: Respiratory disorders
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for pneumonia with increased work of breathing. Asses…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for pneumonia with increased work of breathing. Assessment data include bilateral calf pain with redness and warmth after bedrest. 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. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
D. Ignore small changes until they become severe.
B. Delay teaching until the day of discharge only.
C. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
D. Ignore small changes until they become severe.
Rationale
Correct answer: C. 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.