Level: Foundational
Difficulty: Easy
Subtopic: Fluid volume excess and deficit
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to fluid volume excess and d…
Pathophysiology Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for nursing care related to fluid volume excess and deficit. Assessment data include bilateral calf pain with redness and warmth after bedrest. 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.