Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?

Correct Answer: A

Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.

Correct Answer: B

Rationale: The correct response is to explain to the client what nearsightedness means, which is having difficulty seeing distant objects, as known as myopia. Choice A is not helpful as changing doctors is not necessary for this situation. Choice C is premature as wearing glasses is a possible solution but not the only one. Choice D is incorrect as nearsightedness (myopia) often requires glasses for correction.

Correct Answer: A

Rationale: The best nursing intervention for a client with limited mobility who cannot move independently is passive range of motion. Passive range of motion exercises help maintain joint flexibility, prevent contractures, and improve circulation in immobile clients. Choice B, pillows for positioning, may provide comfort but does not address the need for joint movement. Choice C, active range of motion, requires the client's active participation, which is not feasible for someone with limited mobility. Choice D, continuous passive motion, is more commonly used in rehabilitation settings for specific joints and is not typically the primary intervention for overall limited mobility.

Correct Answer: A

Rationale: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.

Correct Answer: A

Rationale: **Rationale:** **A: Client who had recent cataract surgery and worsening vision** is the highest priority. Postoperative complications following cataract surgery, such as endophthalmitis (a severe intraocular infection) or retinal detachment, can lead to rapid and irreversible vision loss if not addressed immediately. Worsening vision after cataract surgery is a red flag that demands urgent evaluation to rule out these sight-threatening conditions. Delay in treatment could result in permanent damage, making this client the top priority. **B: Client with an absent red reflex** is concerning but may not always require immediate intervention. An absent red reflex can indicate conditions like retinal detachment, vitreous hemorrhage, or advanced cataracts. While serious, some causes (e.g., dense cataract) may not be emergencies, whereas others (e.g., retinal detachment) would be. However, without additional symptoms like acute vision loss or pain, this finding alone is less urgent than a postoperative complication. **C: Client with an intraocular pressure (IOP) of 24 mmHg** is not the most urgent case. While elevated IOP can suggest glaucoma, 24 mmHg is only mildly elevated and may not cause immediate harm. Acute angle-closure glaucoma (which presents with severe pain, vision loss, and IOP >40 mmHg) would be emergent, but this scenario lacks those symptoms. This client can be seen after more urgent cases. **D: Client with a tearing, reddened eye with exudate** likely has conjunctivitis, which, while uncomfortable, is typically non-vision-threatening and not an emergency. Bacterial or viral conjunctivitis can be managed with topical treatments and does not require immediate attention unless there is corneal involvement or severe pain, which is not indicated here. This client can wait compared to the postoperative case. In summary, **A** is the correct answer because postoperative vision changes after cataract surgery are potentially sight-threatening and require immediate assessment. The other options involve conditions that, while notable, are either less urgent or lack the immediate risk of permanent vision loss.