Level: Clinical
Difficulty: Medium
Subtopic: Acid-base imbalance
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to acid-base imbalance. Asse…
Pathophysiology Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for nursing care related to acid-base imbalance. Assessment data include temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: A. The new finding that temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion.
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.