Prioritization & Delegation Practice Test #4: Stable vs Unstable Clients

Answer: B. A client 1 day after a transurethral resection of the prostate (TURP) with continuous bladder irrigation running, whose urine is light pink with no clots

Rationale: Light pink urine without clots is an expected finding the day after a TURP. The irrigation is adjusted according to the prescription and facility protocol to keep the urine light pink, and the nurse watches for clots, bright red or thick drainage, and decreased outflow. The other three clients have new, unexpected changes. New confusion with a flapping tremor (asterixis) in a client with cirrhosis suggests hepatic encephalopathy. Flushing and a rash on the upper body during a vancomycin infusion is an infusion reaction; the infusion is usually stopped or slowed and the client is checked for low blood pressure. Black, tarry stools in a client taking warfarin suggest gastrointestinal bleeding and need vital signs, a check of the INR, and a call to the provider.

Answer: D. Serum potassium of 6.8 mEq/L with tall, peaked T waves on the cardiac monitor

Rationale: A high potassium level together with ECG changes such as peaked T waves can lead quickly to dangerous dysrhythmias and cardiac arrest, so it must be reported right away. The provider may order emergency treatment or move dialysis up. In end-stage kidney disease, a high creatinine, a high BUN, and anemia are expected chronic findings because the kidneys can no longer clear waste or make enough erythropoietin. They are documented and followed, but they are not the emergency here. Normal ranges vary by laboratory, so always compare results with the facility's reference values and the client's own trend.

Answer: A. A client with a head injury whose Glasgow Coma Scale score has dropped from 14 to 11 since the last check

Rationale: A drop in the Glasgow Coma Scale score is a sign of neurological deterioration, often from rising intracranial pressure or bleeding, and a fall of 2 points or more is generally treated as significant. The nurse completes a focused neuro check and notifies the provider or calls the rapid response team per facility policy. The other three findings match each client's known baseline: limited orientation in Alzheimer disease, unchanged weakness after a stroke, and a resting tremor in Parkinson disease. Stable means unchanged from baseline, not normal.

Answer: C. New low back pain, with a heart rate that has risen from 78/min to 112/min

Rationale: New back or flank pain with a rising heart rate after a femoral artery puncture suggests a retroperitoneal bleed. This bleeding happens behind the abdomen, so the dressing may look dry while the client loses a large amount of blood. The nurse checks vital signs and the site, keeps the client flat, and notifies the provider or rapid response team right away. A small bruise that is not growing is expected. Strong, equal pedal pulses show good circulation to the leg. Frequent urination is expected because the contrast dye acts as an osmotic diuretic and the client usually receives IV fluids.

Answer: B. A client 2 hours after a vaginal birth whose fundus is boggy and pushed to the right, who has soaked a perineal pad in 15 minutes

Rationale: A boggy fundus, a fundus displaced to one side (often by a full bladder), and saturating a pad in 15 minutes are signs of postpartum hemorrhage. The nurse massages the fundus, helps the client empty her bladder, stays with her, and notifies the provider; uterotonic medications are given per prescription and protocol. A firm, midline fundus at the umbilicus on the day of birth is expected. Moderate lochia rubra with a few small clots in the first days is expected; large clots or heavy bleeding are not. Cramping during breastfeeding (afterpains) is expected because breastfeeding releases oxytocin, which contracts the uterus.

Answer: D. A client with pyelonephritis who is newly confused, with a heart rate of 120/min, a respiratory rate of 26/min, and a blood pressure of 86/50 mm Hg

Rationale: New confusion, a fast heart rate, fast breathing, and low blood pressure in a client with a known infection are warning signs of sepsis and possible septic shock. The nurse calls the rapid response team or provider and starts the facility's sepsis protocol, which commonly includes cultures, a lactate level, IV fluids, and antibiotics as prescribed. The other three clients are stable or improving: the fever is coming down, the cellulitis is shrinking inside the marked line, and the client with pneumonia has a productive cough with adequate oxygenation.

Answer: A. A client with a T4 spinal cord injury who reports a pounding headache, is flushed and sweating above the level of injury, and has a blood pressure of 196/104 mm Hg

Rationale: A pounding headache, flushing and sweating above the injury, and a very high blood pressure in a client with a spinal cord injury at T6 or above are signs of autonomic dysreflexia, a medical emergency that can cause a stroke or seizure. The nurse sits the client up, lowers the legs, loosens tight clothing, looks for the trigger (most often a full bladder, then the bowel or skin), and notifies the provider. Repositioning that is due in 30 minutes can wait. Afternoon fatigue is common in multiple sclerosis. Mild pain with movement in both legs is expected after a laminectomy.

Answer: C. Sudden relief of pain, followed by a rigid, board-like abdomen

Rationale: Sudden relief of pain followed by a rigid, board-like abdomen suggests the appendix has ruptured and peritonitis is developing. The nurse checks vital signs and notifies the surgeon right away. Right lower quadrant pain, a low-grade temperature, loss of appetite, and nausea are typical findings of appendicitis that the team is already treating. A sudden change in a client's condition, even one that looks like improvement, always needs a fresh assessment.

Answer: D. A client with new atrial fibrillation at 152/min who feels dizzy and has a blood pressure of 82/48 mm Hg

Rationale: A rhythm is judged unstable by how the client is tolerating it. Signs of poor perfusion, such as low blood pressure, dizziness or altered mental status, chest pain, or signs of shock, mean the client needs immediate help. This client has a new fast rhythm with low blood pressure and dizziness, so the nurse calls the provider or rapid response team. Treatment, which may include synchronized cardioversion, follows the provider's orders and current resuscitation guidelines. A slow heart rate in a fit athlete with a normal blood pressure, controlled long-standing atrial fibrillation, and occasional PVCs with no symptoms are all stable.

Answer: A. A small amount of serosanguineous drainage in the closed-suction (Jackson-Pratt) drain

Rationale: A small amount of serosanguineous (pink, thin) drainage in a surgical drain is expected after abdominal surgery; the nurse records the amount and color and watches the trend. A sudden gush of pink fluid with a feeling that something gave way suggests wound dehiscence; the nurse stays with the client, positions with knees bent, covers the wound with sterile saline-moistened dressings, and notifies the surgeon. A red, warm, swollen, tender calf suggests deep vein thrombosis. Urine output of 15 mL per hour is below commonly used thresholds (often about 30 mL/hr or 0.5 mL/kg/hr, depending on the client and facility) and may signal hypovolemia or kidney injury, so it needs to be reported.