Level: Clinical
Difficulty: Medium
Subtopic: Neurologic control and level of consciousness
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to neurologic control and le…
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for nursing care related to neurologic control and level of consciousness. Assessment data include the client develops redness and warmth at an IV insertion site. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. The new finding that the client develops redness and warmth at an IV insertion site.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. The new finding that the client develops redness and warmth at an IV insertion site.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: B. The new finding that the client develops redness and warmth at an IV insertion site.
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.