Level: Foundational
Difficulty: Easy
Subtopic: Gastrointestinal disorders
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for partial bowel obstruction. Assessment data includ…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for partial bowel obstruction. Assessment data include bilateral calf pain with redness and warmth after bedrest. 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 bilateral calf pain with redness and warmth after bedrest.
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 bilateral calf pain with redness and warmth after bedrest.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that bilateral calf pain with redness and warmth after bedrest.
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.