A nurse in a long-term care facility has just received change-of-shift report. Which of the following clients should the nurse attend to first?

A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL)

A client who has a spinal cord injury and needs a dressing change

A client who has a temperature of 38.4° C (101.1 F) and appears confused

A client who had a hip arthroplasty and is requesting pain medication

Answer and Explanation

The Correct Answer is C

A. A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL): A mildly elevated blood glucose level is not immediately life-threatening and can be managed after addressing more urgent issues. This client is stable at the moment.

B. A client who has a spinal cord injury and needs a dressing change: While important for preventing infection, a scheduled dressing change is not an immediate threat to the client’s life or health and can be safely performed after more urgent concerns are addressed.

C. A client who has a temperature of 38.4° C (101.1° F) and appears confused: Fever and new-onset confusion suggest a possible infection, such as sepsis or urinary tract infection, especially in older adults. This situation indicates a potential life-threatening condition and requires immediate assessment and intervention.

D. A client who had a hip arthroplasty and is requesting pain medication: Managing pain is important, but it is not immediately life-threatening. After addressing the client with fever and confusion, attending to the client's pain needs would be appropriate.

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Correct Answer is C

Explanation

A. "I have switched from tobacco cigarettes to electronic cigarettes.": Although electronic cigarettes may reduce exposure to certain harmful chemicals found in tobacco smoke, they still pose significant health risks. This change does not reflect truly limiting risky behavior but rather substituting one form of risk for another.

B. "Sometimes I am exposed to toxic chemicals at my workplace, but not any that have harmed me.": Exposure to toxic chemicals, even without immediate harm, still represents ongoing risk. A proactive approach would involve using protective equipment or seeking safer work conditions.

C. "Two of my grandparents had diabetes, so I try to eat a healthy diet.": Actively modifying diet in response to a family health history shows a positive, preventative approach and reflects conscious efforts to limit risk-taking behaviors and promote long-term health.

D. "My job and home life are both very stressful, but I haven't been able to do anything about that.": Chronic unmanaged stress is a health risk, and acknowledging stress without taking steps to manage it indicates that the client is not effectively limiting risk behaviors.

A. Medication B. Route C. Dosage D. Time

Correct Answer is B

Explanation

A. Medication: The medication, erythromycin, is clearly stated and appropriately spelled. There is no confusion about what drug the provider intended to prescribe, so there is no immediate need to clarify the medication name itself.

B. Route: The prescription does not specify the route of administration, which is essential for safe medication delivery. Erythromycin can be given orally or intravenously, and using the wrong route could lead to serious complications. Clarifying the route ensures proper technique and absorption.

C. Dosage: The dosage of 500 mg is within the standard therapeutic range for erythromycin, depending on the severity and type of infection. Since the dose appears appropriate, it does not require immediate clarification unless clinical concerns arise.

D. Time: Although "four times per day" is broad, it is generally understood as approximately every six hours. While more exact times can improve consistency, missing the route of administration is a more critical and urgent issue to clarify for client safety.

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A nurse in a long-term care facility has just received change-of-shift report. Which of the following clients should the nurse attend to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is B

Explanation

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