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 surgical incision with purulent drainage and fever 101.5°F (38.6°C). Which intervention best reduces the client's risk of complications?
Question
A. Restrict all movement without individualized assessment.
B. Delay teaching until the day of discharge only.
C. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
D. Ignore small changes until they become severe.
B. Delay teaching until the day of discharge only.
C. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
D. Ignore small changes until they become severe.
Rationale
Correct answer: C. 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.