A female client with acute respiratory distress syndrome (ARDS) is sedated and on a ventilator with 50% FIO2. What assessment finding warrants immediate intervention?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Diminished left lower lobe sounds. This finding warrants immediate intervention because it indicates a potential complication such as a possible pneumothorax, which can be life-threatening for the client with ARDS. As the left lower lobe sounds are diminished, it suggests a problem with ventilation in that area, requiring prompt assessment and action. Option A) Assess the client's lung sounds bilaterally, while important, does not specifically address the critical issue of diminished sounds in a specific lobe. Option C) Monitoring ventilator settings for changes in oxygen levels is essential but does not directly address the urgent need for intervention indicated by diminished lung sounds. Option D) Increased sputum production and shortness of breath are concerning symptoms but do not address the immediate need for intervention indicated by diminished left lower lobe sounds. Educationally, understanding the significance of assessing lung sounds comprehensively and recognizing specific abnormal findings is crucial for nurses caring for clients with ARDS. This knowledge can help prioritize interventions and prevent potential complications in critically ill patients.

Correct Answer: C

Rationale: In the context of a postoperative client with a history of diabetes mellitus showing signs of hyperglycemia, the nurse should assess the client's capillary blood glucose level first (Option C). This is crucial because hyperglycemia can lead to serious complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state, which require immediate intervention. Monitoring the blood glucose level helps in determining the severity of hyperglycemia and guides appropriate treatment. Assessing for signs of infection (Option A) is important in a postoperative client, but hyperglycemia needs immediate attention to prevent complications specific to diabetes. Monitoring fluid intake and output (Option B) is essential for overall assessment but does not directly address the priority of managing hyperglycemia. Assessing serum potassium level (Option D) is important, but correcting hyperglycemia takes precedence to prevent electrolyte imbalances associated with uncontrolled diabetes. In an educational context, understanding the priority assessment in a client with diabetes experiencing postoperative hyperglycemia is crucial for nurses to provide timely and effective care. This scenario highlights the significance of prioritizing assessments based on the client's condition and the potential risks associated with uncontrolled hyperglycemia.

Correct Answer: A

Rationale: In this scenario, the nurse's primary concern should be monitoring for signs of a pulmonary embolism (PE) when a client reports unilateral leg swelling after a long flight. This is because deep vein thrombosis (DVT) is a common risk associated with prolonged immobility during flights, and a PE is a serious complication of a DVT where a blood clot travels to the lungs, potentially causing life-threatening consequences. Option A is correct because it directly addresses the most critical and time-sensitive complication in this situation. Option B, assessing for signs of dehydration, is less relevant in this context as unilateral leg swelling after a long flight is more indicative of a circulatory issue rather than dehydration. Option C, monitoring for signs of compartment syndrome, is also not the priority as compartment syndrome typically presents with severe pain, pallor, pulselessness, paresthesia, and paralysis, which are not mentioned in the scenario. Option D, checking the client's oxygen saturation levels, is not the immediate concern when a client presents with unilateral leg swelling after a long flight, as the primary focus should be on ruling out a PE. Educationally, understanding the priority of nursing assessments based on the client's presentation is crucial for providing safe and effective care, especially in high-risk situations like post-flight leg swelling. Nurses must be able to recognize potential complications promptly to initiate appropriate interventions and prevent adverse outcomes.

Correct Answer: B

Rationale: The correct answer is B) Check the client's blood pressure for signs of hypotension. In the context of a client with a recent myocardial infarction prescribed a beta-blocker, monitoring for hypotension is crucial because beta-blockers can cause a decrease in blood pressure. This is a common side effect of beta-blockers due to their mechanism of action in blocking the effects of adrenaline on the heart. Hypotension can lead to decreased perfusion to vital organs and exacerbate cardiac issues. Option A) Monitor the client for bradycardia is incorrect because while beta-blockers can slow the heart rate, bradycardia is not the primary side effect to monitor for in this scenario. Option C) Monitor the client for signs of hyperglycemia is incorrect because beta-blockers are more likely to cause hypoglycemia rather than hyperglycemia. Option D) Monitor for signs of fluid retention is incorrect because beta-blockers are not typically associated with fluid retention; in fact, they are often used to manage conditions like heart failure where fluid retention is a concern. Understanding the common side effects of medications and their implications in specific clinical contexts is essential for nurses to provide safe and effective care to their patients, especially those with cardiac conditions like myocardial infarction. Regular monitoring and assessment help in early identification and management of potential complications.

Correct Answer: B

Rationale: A neurological assessment is the priority when a stroke is suspected to determine the extent of brain injury and identify any immediate risks, such as impaired airway, speech deficits, or loss of motor function. Early recognition of these signs is essential for timely intervention and to guide further treatment like the administration of tPA, if appropriate.