Question

Which assessment data would warrant immediate intervention by the nurse?

a. The client diagnosed with DVT who complains of pain on inspiration.
b. The immobile client who has refused to turn for the last 3 hours.
c. The client who had an open cholecystectomy who refuses to breathe deeply.
d. The client who has had an inguinal hernia repair who must void before discharge.

Answer 1

A client with DVT complaining of pain on inspiration requires immediate intervention due to the risk of a life-threatening pulmonary embolism, which is of greater urgency than the other scenarios provided.

Step-by-step explanation:

The assessment data that would warrant immediate intervention by the nurse is: a. The client diagnosed with DVT who complains of pain on inspiration. This symptom may indicate a serious condition called a pulmonary embolism (which results when a blood clot moves to the lungs), particularly in a client with known deep vein thrombosis (DVT). Immediate assessment and potential treatment are critical to prevent life-threatening complications.

While the other scenarios also require nursing care, they do not present immediate life-threatening situations like a potential pulmonary embolism does. A client not turning for 3 hours or refusing to breathe deeply post-surgery, or needing to void before discharge, although important, do not compare in urgency to the critical nature of a possible pulmonary embolism.