🔷 An oxygen saturation of 89% is the priority because it indicates hypoxemia and impaired oxygenation.

🔷 Using the ABC priority framework, breathing problems are addressed before pain, bleeding concerns, or elevated blood pressure.

🔷 A postoperative client is at risk for atelectasis, hypoventilation, pneumonia, and opioid-related respiratory depression.

🔷 Low oxygen saturation can rapidly progress to respiratory distress if not reported and managed promptly.

🔷 The nurse should report this finding to the provider and anticipate interventions such as oxygen therapy, lung assessment, repositioning, coughing, deep breathing, or incentive spirometry.

Report of pain as 7 on a scale of 0 to 10.

🔷Pain of 7 is significant and requires intervention.

🔷It is not the priority over oxygen saturation of 89%, which reflects an immediate breathing concern.

Bright red drainage on surgical dressing.

🔷Bright red drainage can indicate active bleeding and should be assessed further.

🔷However, impaired oxygenation takes priority because breathing is immediately life-sustaining.

Blood pressure 160/80 mm Hg.

🔷This blood pressure is elevated and should be monitored.

🔷It is less urgent than hypoxemia in a postoperative client.

🟢 Wound evisceration occurs when internal organs protrude through a separated surgical incision.

🟢 The priority action is to cover the exposed tissue with sterile gauze moistened with normal saline.

🟢 Moist sterile dressings protect the organs from drying, contamination, and tissue damage.

🟢 The nurse should also place the client in a low Fowler’s position with knees flexed if possible to reduce tension on the abdomen.

🟢 This is a surgical emergency, so the provider should be notified after protecting the exposed tissue.

Raise the head of the bed to a 45° angle.

🟢Raising the head of the bed too high can increase tension on the abdominal incision.

🟢A lower position with knees flexed is preferred to reduce abdominal strain.

Hold gentle, direct pressure on the protruding organ.

🟢Direct pressure should not be applied to protruding organs because it can damage tissue and impair circulation.

🟢The organs should be protected with moist sterile dressings.

Place the client’s knees in an extended position.

🟢Extending the knees increases abdominal tension.

🟢Flexing the knees helps decrease strain on the incision.

🟣 A client with idiopathic thrombocytopenic purpura has a low platelet count and increased risk for bleeding.

🟣 The MMR vaccine is given subcutaneously and has been associated with thrombocytopenia in rare cases.

🟣 Because this student already has a platelet disorder, the vaccine should be withheld until the provider evaluates safety.

🟣 Live vaccines may also require careful review when immune or hematologic concerns are present.

🟣 The nurse should follow school health policy and consult the healthcare provider regarding vaccine timing.

Polio.

🟣The inactivated polio vaccine is not typically withheld for idiopathic thrombocytopenic purpura.

🟣It does not carry the same concern as MMR in this situation.

Diphtheria and tetanus toxoids and pertussis.

🟣This vaccine is not the priority to withhold for ITP.

🟣The main concern is the MMR vaccine because of its association with thrombocytopenia.

Hepatitis B.

🟣Hepatitis B vaccine is generally safe for clients with platelet disorders, although injection technique may need attention.

🟣It is not the scheduled vaccine most associated with this concern.

🔴 Tuberculosis is transmitted by airborne droplet nuclei that can remain suspended in the air.

🔴 Routine care for a client with active tuberculosis requires airborne precautions.

🔴 The nurse should wear a fit-tested N95 respirator before entering the client’s room.

🔴 A standard surgical mask does not provide adequate respiratory protection against airborne TB particles.

🔴 The client should be placed in a negative-pressure room when available to reduce transmission risk.

Surgical mask.

🔴A surgical mask protects against large droplets but does not filter airborne particles effectively.

🔴It is not sufficient protection for active tuberculosis care.

Shoe protectors.

🔴Shoe protectors are not required for routine care of a client with tuberculosis.

🔴TB is spread through airborne particles, not through shoes.

Sterile gloves.

🔴Sterile gloves are used for sterile procedures, not routine tuberculosis care.

🔴Standard gloves may be used when contact with body fluids is expected, but the key PPE is an N95 respirator.

Client reports pain level as 10 on a scale of 0 to 10

🔴 Severe pain rated 10/10 after a leg fracture with a cast is a major warning sign of acute compartment syndrome.

🔴 Pain from compartment syndrome is often severe, progressive, and not relieved by opioids.

🔴 The cast may be contributing to increased pressure around the injured extremity.

🔴 Untreated compartment syndrome can cause ischemia, nerve damage, tissue necrosis, and limb loss.

🔴 This finding requires immediate follow-up and rapid reporting to the RN or provider.

Right lower extremity elevated on pillow

🔴 In suspected compartment syndrome, the extremity should generally be kept at heart level, not elevated high above the heart.

🔴 Elevation can reduce arterial blood flow to an already compromised extremity.

🔴 The client is showing signs of poor perfusion, including pale toes, cool skin, numbness, and limited movement.

🔴 This position may worsen tissue ischemia if circulation is already impaired.

🔴 The PN should follow up immediately and report the neurovascular changes.

Last dose of pain medication “did not help my pain much”

🔴 Pain that is not relieved by opioid medication is a classic sign of compartment syndrome.

🔴 This suggests the pain is related to increased tissue pressure and decreased perfusion, not routine postoperative or fracture pain.

🔴 The client received hydrocodone/acetaminophen, yet the pain worsened from 7/10 to 10/10.

🔴 Worsening pain despite medication indicates a serious complication requiring immediate assessment.

🔴 This finding should not be treated only by giving stronger pain medication.

Pain medication “made my toes numb”

🔴 Toe numbness indicates paresthesia, which is an early sign of neurovascular compromise.

🔴 The numbness is more likely related to decreased nerve perfusion than to the pain medication.

🔴 Nerve compression can progress quickly if pressure inside the casted extremity continues to rise.

🔴 This finding is especially concerning because it occurs with pale, cool toes and limited movement.

🔴 Immediate follow-up is needed to prevent permanent nerve injury.

Blood pressure 159/88 mm Hg

🔴 The elevated blood pressure can reflect the body’s response to severe uncontrolled pain.

🔴 Acute pain activates the sympathetic nervous system, causing increased blood pressure and heart rate.

🔴 This change is significant because it occurs with worsening neurovascular findings.

🔴 The PN should not view the blood pressure as an isolated finding.

🔴 It supports the need for immediate reassessment and reporting.

Heart rate 112/min

🔴 A heart rate of 112/min indicates tachycardia.

🔴 Tachycardia can occur with severe pain, stress, early shock, or worsening tissue injury.

🔴 In this case, it is concerning because it appears with severe pain and signs of impaired circulation.

🔴 The increasing heart rate from 78/min to 112/min shows clinical deterioration.

🔴 This finding requires immediate follow-up with the other abnormal cues.

Respiratory rate 22/min

🔴 A respiratory rate of 22/min is elevated and suggests physiologic stress.

🔴 Increased respirations may occur because of severe pain, anxiety, or developing complications.

🔴 The change from 16/min to 22/min shows worsening status.

🔴 This is important when combined with labored breathing and tachycardia.

🔴 The PN should report this change as part of the client’s deterioration.

Respirations labored

🔴 Labored respirations indicate the client is working harder to breathe.

🔴 Severe pain can increase oxygen demand and cause respiratory distress.

🔴 Although breath sounds are clear, labored breathing is still abnormal.

🔴 This finding adds to the concern that the client is experiencing worsening physiologic stress.

🔴 It requires immediate follow-up along with the neurovascular changes.

Increasing edema to toes

🔴 Increasing edema below a cast suggests worsening swelling in the injured extremity.

🔴 Swelling inside a confined cast can increase tissue pressure and impair circulation.

🔴 This is a major concern for acute compartment syndrome.

🔴 Edema with pale toes, cool skin, numbness, and limited movement indicates poor perfusion.

🔴 The PN should report this immediately because the cast may need urgent intervention.

Toes pale

🔴 Pale toes indicate decreased arterial perfusion to the distal extremity.

🔴 This is a serious neurovascular finding after fracture and casting.

🔴 Pale skin suggests that oxygenated blood is not reaching the tissues adequately.

🔴 When combined with cool skin and limited movement, it strongly suggests compromised circulation.

🔴 Immediate follow-up is required to prevent tissue ischemia.

Swelling limiting movement of toes significantly

🔴 Limited toe movement suggests impaired motor function in the affected extremity.

🔴 Motor weakness can occur when nerves and muscles are compressed by increasing compartment pressure.

🔴 This is a late and serious finding of neurovascular compromise.

🔴 The change from moving toes without difficulty to significantly limited movement shows deterioration.

🔴 This finding requires urgent reporting and intervention.

Skin cool

🔴 Cool skin indicates decreased blood flow to the affected extremity.

🔴 This finding is concerning because the skin was previously warm at 1500.

🔴 A change from warm to cool suggests worsening circulation beneath the cast.

🔴 Cool skin with pale toes, edema, numbness, and severe pain is highly suspicious for compartment syndrome.

🔴 This requires immediate follow-up to prevent permanent tissue damage.

🟣 Chemotherapy can cause xerostomia, stomatitis, and oral mucosal irritation because it affects rapidly dividing cells in the mouth.

🟣 Artificial saliva helps relieve dry mouth, improves comfort, supports swallowing, and protects fragile oral tissues.

🟣 Maintaining oral moisture lowers the risk of cracking, ulceration, infection, and oral candidiasis.

🟣 The client should also use gentle oral hygiene, a soft-bristled toothbrush, and bland rinses such as saline or baking soda solution.

🟣 This instruction is appropriate because it protects the oral mucosa during cancer treatment.

“Rinse mouth with an alcohol-based mouthwash after every meal.”

🟣Alcohol-based mouthwash can worsen dryness, burning, and mucosal irritation.

🟣Clients receiving chemotherapy should use mild, nonalcoholic rinses.

“Consume acidic foods to limit the development of oral candidiasis.”

🟣Acidic foods can irritate inflamed oral tissues and worsen stomatitis.

🟣They do not prevent oral candidiasis.

“Use a firm-bristled toothbrush to brush teeth.”

🟣A firm-bristled toothbrush can injure fragile oral mucosa and increase bleeding risk.

🟣A soft-bristled toothbrush is recommended.

Condition

Heart failure

💠 The client is most likely experiencing heart failure because the assessment shows fluid volume overload.

💠 Findings such as S3 heart sound, bilateral crackles, +3 lower extremity edema, weight gain, tachycardia, and increased respiratory rate strongly support worsening heart failure.

💠 The client gained about 1.8 kg/3.9 lb from 86.4 kg to 88.2 kg, which suggests fluid retention.

💠 The BNP is 350 ng/L, which is elevated above the expected level of less than 100 ng/L and supports ventricular strain.

💠 These findings indicate the heart is not pumping effectively, causing fluid to back up into the lungs and peripheral tissues.

Actions

Request a prescription for a diuretic

🔷 A diuretic helps remove excess fluid in clients with heart failure and fluid overload.

🔷 This client has bilateral crackles, +3 edema, weight gain, and elevated BNP, which indicate fluid retention.

🔷 Diuretics reduce circulating volume, decrease pulmonary congestion, and improve breathing.

🔷 Requesting a prescription is appropriate because the nurse needs provider authorization to administer the medication.

🔷 The response helps address the underlying problem of excess fluid accumulation.

Instruct the client about sodium restriction

🔷 Sodium restriction is important because sodium causes the body to retain water.

🔷 In heart failure, excess sodium intake worsens edema, weight gain, and pulmonary congestion.

🔷 Teaching the client to limit sodium helps reduce fluid overload and prevent worsening symptoms.

🔷 Sodium restriction is a key lifestyle intervention used with medication therapy in heart failure management.

🔷 The nurse should reinforce reading food labels, avoiding processed foods, and following the prescribed sodium limit.

Parameters

Daily weight

🟢 Daily weight is one of the best indicators of fluid balance in heart failure.

🟢 Weight gain can reveal fluid retention before worsening edema or respiratory distress becomes severe.

🟢 This client gained about 1.8 kg/3.9 lb, which is clinically significant over a short period.

🟢 Monitoring daily weight helps evaluate whether diuretics and sodium restriction are effective.

🟢 The client should be weighed at the same time each day, using the same scale and similar clothing.

Blood pressure

🟢 Blood pressure should be monitored because heart failure and diuretic therapy can affect hemodynamic stability.

🟢 This client’s blood pressure decreased from 118/68 mm Hg to 108/66 mm Hg, which should be trended.

🟢 Diuretics can reduce circulating volume and may lead to hypotension if fluid loss becomes excessive.

🟢 Blood pressure also helps determine whether the client is tolerating heart failure treatment.

🟢 Monitoring blood pressure supports safe management and early recognition of worsening perfusion.

🔷 The client’s bilateral wrist and shoulder stiffness lasting several hours after waking is strongly associated with rheumatoid arthritis, an inflammatory autoimmune joint disease.

🔷 The positive ANA, fatigue, loss of appetite, mild anemia, and low WBC count support an inflammatory or autoimmune process.

🔷 The ESR level is elevated at both visits, which indicates ongoing systemic inflammation.

🔷 Rheumatoid arthritis commonly causes symmetrical joint stiffness, especially in small joints such as the wrists.

🔷 Morning stiffness that lasts for hours is more consistent with inflammatory arthritis than degenerative joint disease.

🔷 After finding a client on the floor, the nurse should first assess the client’s condition before moving to documentation or notifications.

🔷 Measuring vital signs helps identify immediate problems such as hypotension, bleeding, shock, pain response, or neurologic changes.

🔷 A fall can cause hidden injury, especially if the client hit the head, fractured a bone, or became unstable before falling.

🔷 The nurse should also assess pain, level of consciousness, visible injuries, and ability to move extremities.

🔷 Assessment data guide whether the provider must be notified urgently and what interventions are needed next.

Notify the client’s provider.

🔷The provider should be notified after the nurse completes an immediate assessment.

🔷Calling before assessing delays collection of important clinical information.

Complete an incident report.

🔷An incident report is required after a fall.

🔷It is not the first action because client safety and assessment come first.

Document the fall in the client’s medical record.

🔷Documentation is necessary after assessment and interventions.

🔷It should not occur before checking the client’s current condition.

🔶 Urge incontinence occurs when the client has a sudden, strong need to urinate and may not reach the toilet in time.

🔶 A bladder retraining program helps the client gradually increase the time between voiding episodes.

🔶 Scheduled toileting reduces urgency, improves bladder control, and decreases accidental urine loss.

🔶 The program may include timed voiding, urge suppression techniques, and tracking voiding patterns.

🔶 This intervention supports independence and is a first-line behavioral strategy for urge incontinence.

Increase the client’s intake of citrus juices.

🔶Citrus juices can irritate the bladder and worsen urgency.

🔶Clients with urge incontinence are often taught to limit bladder irritants such as caffeine, alcohol, and acidic drinks.

Reinforce teaching about self-catheterization.

🔶Self-catheterization is more appropriate for urinary retention or overflow incontinence.

🔶It is not the usual first intervention for urge incontinence.

Limit the client’s total daily fluid intake.

🔶Severely limiting fluids can concentrate urine and irritate the bladder.

🔶Clients should maintain adequate hydration while spacing fluids appropriately.