Adult health / medical-surgical nursing · practice question

A 73-year-old client on a telemetry unit is being evaluated for chronic kidney disease with fluid overload. Assessment data include the client has crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath. Which finding requires the nurse to intervene immediately?

Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026adult-health-med-surg

Routine data unchanged from the prior assessment.A stable, long-standing finding that matches the expected care plan.A comfort request with unchanged vital signs and no new symptoms.The new finding that has crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath.

Answer and explanation

Correct answer

D. The new finding that has crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath.

Why

Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.

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A 73-year-old client on a telemetry unit is being evaluated for chronic kidney disease with fluid overload. Assessment data include the client has crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath. Which finding requires the nurse to intervene immediately?

Correct answer

Why

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