A nurse working in a long-term care facility is assigned to care for four clients following the 0700 morning change-of-shift report. Which of the following clients should the nurse attend to first?
A client who has bronchitis, began receiving antibiotics yesterday and has a temperature of 38.3°C (101°F).
A client who has COPD and has an oxygen saturation of 90%.
A client who has Alzheimer's and was restless during the night.
A client who has diabetes and had a 0600 blood glucose level of 60 mg/dL.
The Correct Answer is D
Of the four clients described, the nurse should attend to the client who has diabetes and had a 0600 blood glucose level of 60 mg/dL first. This client's blood glucose level is low and requires immediate intervention to prevent further complications.
Option A may require attention, but the client's condition is stable and they are receiving treatment.
Option B may also require attention, but an oxygen saturation of 90% is within an acceptable range for a client with COPD.
Option C may also require attention, but the client's restlessness during the night does not indicate an immediate need for intervention.
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Related Questions
Correct Answer is B
Explanation
If a charge nurse in an acute care facility receives a client request not to have particular assistive personnel (AP) care for her, the appropriate action for the charge nurse to take is to address the concern with the assigned nurse. This will allow the charge nurse and the assigned nurse to work together to address the client's concerns and ensure that the client receives appropriate care.
Option A is incorrect because documenting the issue on an incident report may be necessary, but it should not be the first action taken.
Option C is incorrect because explaining to the client that the AP was having a bad day does not address the client's concerns or wishes.
Option D is incorrect because notifying the human resources department may be necessary, but it should not be the first action taken.
Correct Answer is A
Explanation
If a nurse is assisting with the care of a group of pediatric clients, the first action the nurse should take is to deliver a breakfast tray to a child who has been administered regular insulin. This is because regular insulin is a fast-acting insulin that begins to lower blood sugar levels within 15 minutes of administration. It is important for the child to eat shortly after receiving regular insulin to prevent hypoglycemia.
Option B is incorrect because completing pin site care for a child who is in skeletal traction is not as time-sensitive as delivering a breakfast tray to a child who has been administered regular insulin.
Option C is incorrect because providing clear liquids to a child who is 4 hr postoperative following a laparoscopic appendectomy is not as time-sensitive as delivering a breakfast tray to a child who has been administered regular insulin.
Option D is incorrect because administering acetaminophen to a child who has a temperature of 101.2°F (38.4°C) is not as time-sensitive as delivering a breakfast tray to a child who has been administered regular insulin.
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