Question

Which of the following assessments made by a nurse during a morning assessment of a client would require immediate intervention? Select all that apply.

-Ten respirations per minute by a sleeping patient
-Rattling sound in the pharynx of an unconscious patient Coughing and expectorating large amounts of thick mucus Slight shortness of breath after returning from the bathroom
-Vomiting of large amount of bright red hemoptysis

Answer 1

The assessments that would require immediate intervention are rattling sound in the pharynx and vomiting of large amount of bright red hemoptysis.

Step-by-step explanation:

From the given options, the assessments that would require immediate intervention during a morning assessment of a client by a nurse are:

• Rattling sound in the pharynx of an unconscious patient: This could indicate airway obstruction, which requires immediate intervention to ensure the patient's airway is clear.
• Vomiting of large amount of bright red hemoptysis: Hemoptysis refers to coughing up blood from the respiratory tract. This could be a sign of severe bleeding and requires prompt medical attention.

The other options mentioned do not indicate immediate intervention is necessary. Ten respirations per minute by a sleeping patient is within the normal range, coughing and expectorating large amounts of thick mucus may indicate respiratory congestion but is not necessarily an emergency, and slight shortness of breath after returning from the bathroom could be due to exertion or other non-urgent factors.