Difficulty: Medium
Average Score: 85%
Simulated
The nurse is caring for the following assigned clients. The nurse should immediately follow up with the client who has
Correct answer
A
Rationale
A low-pressure ventilator alarm (D) suggests a leak or disconnection, risking airway compromise, requiring immediate follow-up. Colostomy refusal (A), periorbital edema (B), and irregular pulse in AF (C) are less urgent, as they are chronic or stable.