The nurse is assessing a mechanically ventilated client with pneumonia after providing deep oral suctioning to the client. Which assessment finding would be unexpected and be a priority for the nurse to address?

Choice A reason: A client who has undergone a cholecystectomy 2 days ago with decreased bowel sounds might be experiencing a common postoperative issue that requires monitoring but may not need immediate intervention. Decreased bowel sounds can result from the effects of anesthesia, pain medications, or the surgical procedure itself. While this condition warrants attention, it is not as urgent as new-onset confusion in another client.

Choice B reason: A client with diabetes mellitus and a blood glucose level of 140 mg/dL is within a manageable range, especially in a hospitalized setting. This level of blood glucose does not indicate immediate danger and can be managed with appropriate insulin or oral medication adjustments. It is important for maintaining overall glucose control, but it does not present an urgent situation requiring immediate prioritization over the other clients.

Choice C reason: A client with a left femur fracture experiencing new-onset confusion is the highest priority. New-onset confusion can be a sign of several serious conditions, such as delirium, infection, or a complication related to the fracture or its treatment. This symptom indicates an acute change in the client's condition that requires immediate assessment and intervention to determine the underlying cause and prevent further complications. Therefore, this client should be prioritized first.

Choice D reason: A client admitted for dehydration with a blood pressure of 105/77 mm Hg has a relatively stable blood pressure reading. While dehydration requires prompt treatment with fluids, this client's condition is not as critical as the client experiencing new-onset confusion. The blood pressure reading indicates that the client is maintaining an adequate circulatory status and can be managed after addressing the more urgent needs of the client with confusion.

Choice A reason: Administering a tap water enema is within the scope of practice for an LPN. This task is a routine procedure that does not require the clinical judgment of a registered nurse (RN). The LPN can safely perform this task under the supervision of the RN.

Choice B reason: Assessing a new admission client is a comprehensive process that involves obtaining a detailed medical history, performing a thorough physical assessment, and developing an initial plan of care. This task requires the clinical judgment and decision-making skills of an RN, making it inappropriate to delegate to an LPN.

Choice C reason: Evaluating a client with new onset chest pain is a critical task that requires immediate attention and advanced assessment skills. It involves determining the cause of the chest pain, assessing the severity, and initiating appropriate interventions. This task must be performed by an RN due to the potential for serious underlying conditions such as myocardial infarction.

Choice D reason: Administering Morphine IV push requires specific knowledge about the medication, potential side effects, and monitoring for adverse reactions. This task involves clinical judgment and decision-making, making it inappropriate to delegate to an LPN. The RN is responsible for administering medications that require close monitoring and assessment.