Level: Clinical
Difficulty: Medium
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 hemoglobin 6.8 g/dL with pallor and hypotension 90/55 mm Hg. Which intervention best reduces the client's risk of complications?
Question
A. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
B. Restrict all movement without individualized assessment.
C. Delay teaching until the day of discharge only.
D. Ignore small changes until they become severe.
B. Restrict all movement without individualized assessment.
C. Delay teaching until the day of discharge only.
D. Ignore small changes until they become severe.
Rationale
Correct answer: A. 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.