A nurse is caring for a client in the emergency department.

Click to highlight the findings that indicate that the client's condition is improving. To deselect a finding, click on the finding again.

Nurses notes:

1400:

Client admitted to the medical-surgical unit at 1200 today. Alert and orientated x4, heart and lung sounds clear. Client urinating 100 mL/hour. Client is tolerating soft diet and oral fluids. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 2+. Blood glucose 310 mg/dL (74 to 106 mg/dL)

Vital signs:

1400:

Temperature 36.8° C (98.2 F)

Pulse rate 84/min

Respiratory rate 16/min

Blood pressure 106/76 mm Hg

Oxygen saturation 96% on room air

A. Encourage frequent ambulation is not appropriate for a client with bacterial meningitis, especially during the acute phase. The client may be experiencing severe headache, fever, and sensitivity to light, and ambulation could worsen these symptoms. Rest and a quiet environment are preferred.

B. Ensure lights are dimmed in the client's room is the correct intervention. Clients with bacterial meningitis often experience photophobia (sensitivity to light), so dimming the lights can help reduce discomfort and create a more comfortable environment.

C. Ensure the client's bed is positioned to greater than 45° is not a standard intervention for bacterial meningitis. While positioning can be important for comfort and airway management, the primary concern in bacterial meningitis is managing infection and symptoms, not positioning.

D. Initiate airborne precautions is not necessary for bacterial meningitis. Bacterial meningitis is typically transmitted through respiratory droplets, so droplet precautions, not airborne precautions, should be implemented.

A. While the Morse Fall Risk scale is important for assessing fall risk, it is not the priority after an ORIF procedure. The client’s neurovascular status should be closely monitored to prevent complications.

B. A neurovascular assessment is the priority after an ORIF of the femur. This includes checking for circulation, sensation, and movement (CSM) in the affected leg to ensure there is no compromise to the blood flow or nerve function. This is crucial to detect complications like compartment syndrome or circulatory impairment early.

C. The Braden scale is used to assess the risk for pressure ulcers and is important but not the priority after surgery. Neurovascular status takes precedence in the postoperative period.

D. Pain assessment is important for managing the client’s comfort, but it is secondary to ensuring proper neurovascular function to prevent further complications such as ischemia or nerve damage.