While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s continuous passive motion (CPM) device.
Which of the following actions should the nurse take first?

This is an example of a therapeutic communication technique that validates the client’s feelings and encourages them to express their emotions verbally rather than physically.
It also shows empathy and respect for the client’s perspective.
Choice A is wrong because engaging the panic alarm is not the first action to take when interacting with an agitated client.
The nurse should first try to calm the client down by using verbal and nonverbal communication skills, such as maintaining eye contact, speaking in a calm and clear voice, and avoiding sudden movements or gestures.
Engaging the panic alarm should be done only if the client becomes violent or poses a threat to themselves or others.
Choice B is wrong because using a face shield with a mask when providing care to the client is not relevant to the situation.
This is personal protective equipment (PPE) that is used to prevent exposure to infectious agents or body fluids, not to manage agitation.
Using a face shield with a mask may also increase the client’s anxiety or paranoia, as they may perceive it as a sign of hostility or fear.
Choice D is wrong because initiating the seclusion protocol is not appropriate for a client who is agitated, pacing, and speaking loudly.
Seclusion is a restrictive intervention that involves isolating the client in a locked room to prevent harm to themselves or others.
It should be used only as a last resort when less restrictive measures have failed or are contraindicated, and only with a provider’s order and close monitoring.
Secluding an agitated client may escalate their behavior and violate their rights.
Normal ranges for agitation are not applicable, as agitation is not a quantifiable parameter.
However, some tools that can be used to assess agitation include the Richmond Agitation- Sedation Scale (RASS), which ranges from -5 (unarousable) to +4 (combative), and the Agitated Behavior Scale (ABS), which ranges from 14 (no agitation) to 56 (severe agitation).

This client should be assessed first because they are at risk of hypoglycemia, which is a medical emergency that can cause seizures, coma, or death if not treated promptly.
The nurse should check the client’s blood glucose level again and provide additional carbohydrates or glucose if needed.
Choice A is wrong because a client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.
The nurse should verify the client’s consent, allergies, and vital signs before the procedure, but this is not a priority over a client with low blood glucose.
Choice B is wrong because a client who received pain medication 30 min ago for postoperative pain is likely to have improved pain relief and does not need immediate assessment.
The nurse should monitor the client’s pain level, vital signs, and respiratory status periodically, but this is not a priority over a client with low blood glucose.
Choice D is wrong because a client who has 100 mL of fluid remaining in his IV bag is not in immediate danger and can be assessed later.
The nurse should change the IV bag when it is empty or nearly empty, but this is not a priority over a client with low blood glucose.
Normal blood glucose levels are between 70 to 100 mg/dL (3.9 to 5.5 mmol/L) when fasting, and less than 140 mg/dL (7.8 mmol/L) two hours after eating. A blood glucose level below 70 mg/dL (3.9 mmol/L) is considered hypoglycemia and requires immediate treatment. Orange juice is a source of simple carbohydrates that can raise blood glucose quickly, but it may not be enough to prevent hypoglycemia in some cases.