A nurse is supervising a licensed practical nurse (PN) who is providing care to a client who is postoperative. Which of the following statements by the client requires the nurse to follow up with the PN?

A. Elevate the client’s head of bed:
Elevating the head of the bed is a good practice for patients on mechanical ventilation as it helps prevent complications such as aspiration. However, in the scenario where the client has pulled out the endotracheal tube, the immediate concern is assessing the airway and ensuring adequate oxygenation and ventilation. Elevating the head of the bed can be done later as needed.

B. Assess the client’s airway:
This is the correct and priority action. The nurse should assess the client's airway first to determine the extent of the situation. This involves checking for signs of airway obstruction, respiratory distress, or inadequate oxygenation. The assessment guides subsequent interventions.

C. Prepare the client for intubation:
While preparing for intubation may be necessary if the endotracheal tube is completely displaced, assessing the airway comes first. The nurse needs to gather information about the client's current condition before deciding on the appropriate course of action.

D. Suction the client’s mouth:
Suctioning may be necessary, especially if there are secretions or other obstructions in the mouth or airway. However, it should come after the initial assessment of the airway. If the client's airway is clear, suctioning may not be the immediate priority.

A. Pain in the affected leg could indicate worsening of cellulitis or a potential complication like deep vein thrombosis (DVT), but there is no immediate indication of a life-threatening condition. This client should be assessed, but may not be the top priority unless other signs of complications are present.

B. A serum calcium level of 10 mg/dL is within the normal range (8.5 to 10.5 mg/dL). A headache, while concerning, is not immediately life-threatening unless there are additional symptoms suggesting something more severe.

C.Reddish brown urine suggests hematuria, a symptom of glomerulonephritis. This could indicate ongoing kidney issues, but unless there are signs of severe kidney failure or systemic infection, this might not be the most urgent case.

D. A blood glucose level of 68 mg/dL is low and can lead to hypoglycemia, which can be immediately life-threatening if it progresses to severe hypoglycemia. Symptoms of hypoglycemia include confusion, dizziness, sweating, and can escalate to seizures or unconsciousness if not promptly treated.