Ati Med Surg Proctored Exam
A nurse is caring for a group of clients on a medical unit. For which of the following clients should the nurse intervene immediately?
Explanation & Rationale
A. Urinary incontinence in an immobile client is important to address to prevent skin breakdown but does not require immediate intervention. B. Aphasia (difficulty speaking or understanding language) developing in a client with a concussion could indicate worsening neurological status or increased intracranial pressure, which is a medical emergency. This requires immediate intervention. C. A urine output of 260 mL over 8 hours is slightly low (normal is ~30 mL/hr) but not yet critical. D. An oxygen saturation of 93% is acceptable for a client with COPD.
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