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 nosebleeds once per week.": Occasional nosebleeds are relatively common during pregnancy due to hormonal changes causing increased vascularity and congestion of the nasal passages. While the frequency should be noted, it's generally not a priority to report unless they are severe, frequent, or difficult to control.

B. "My heart feels like it skips a beat.": Palpitations can occur during pregnancy because of increased blood volume and changes in cardiovascular function. Occasional palpitations are typically benign but should be further evaluated if they become persistent or are associated with other symptoms like chest pain.

C. "I am experiencing persistent headaches.": Persistent headaches during pregnancy, especially after 20 weeks gestation, can be a warning sign of preeclampsia, a serious hypertensive disorder. Reporting this symptom immediately is critical to assess for elevated blood pressure, proteinuria, and other complications.

D. "The palms of my hands are red and blotchy.": Red, blotchy palms, known as palmar erythema, are a common and harmless finding during pregnancy due to increased estrogen levels. It does not usually indicate any serious condition and does not require urgent reporting.

A. Pain radiating down the left arm B. Seizure activity C. Sudden loss of vision in one eye D. Epigastric pain

Correct Answer is C

Explanation

A. Pain radiating down the left arm: Pain radiating to the left arm is more commonly associated with myocardial infarction (heart attack), not a transient ischemic attack (TIA). It indicates cardiac ischemia rather than a temporary disruption in cerebral blood flow.

B. Seizure activity: Seizures are not characteristic of transient ischemic attacks. While seizures can occur after significant brain injury such as a stroke, TIAs typically present with focal neurological deficits that resolve quickly without leading to seizure activity.

C. Sudden loss of vision in one eye: A sudden, temporary loss of vision in one eye (amaurosis fugax) is a classic sign of a TIA. It reflects temporary ischemia in the retinal or cerebral blood vessels and warrants immediate medical evaluation to prevent a full-blown stroke.

D. Epigastric pain: Epigastric pain is usually related to gastrointestinal issues such as gastritis, ulcers, or gallbladder disease. It is not indicative of a transient ischemic attack and would not typically be prioritized in assessing for neurological compromise.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse
Vital Signs	Temperature 35.3°C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch.
Cardiopulmonary	Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even, nonlabored.
Abdomen	Abdomen soft, nondistended. Bowel sounds hypoactive in all four quadrants. 2x2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant. Moderate amount of sanguineous drainage noted on the lower dressing

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?

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