Level: Advanced
Difficulty: Hard
Subtopic: IV therapy and compatibility
NCLEX: A 55-year-old client in postanesthesia care is being evaluated for continuous IV fluid therapy. Assessment data i…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 55-year-old client in postanesthesia care is being evaluated for continuous IV fluid therapy. Assessment data include the client has new facial swelling and difficulty swallowing after the first dose. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that has new facial swelling and difficulty swallowing after the first dose.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that has new facial swelling and difficulty swallowing after the first dose.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that has new facial swelling and difficulty swallowing after the first dose.
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.