A nurse in a long-term care facility has just received change-of-shift report. Which of the following clients should the nurse attend to first?
A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL)
A client who has a spinal cord injury and needs a dressing change
A client who has a temperature of 38.4° C (101.1 F) and appears confused
A client who had a hip arthroplasty and is requesting pain medication
The Correct Answer is C
A. A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL): A mildly elevated blood glucose level is not immediately life-threatening and can be managed after addressing more urgent issues. This client is stable at the moment.
B. A client who has a spinal cord injury and needs a dressing change: While important for preventing infection, a scheduled dressing change is not an immediate threat to the client’s life or health and can be safely performed after more urgent concerns are addressed.
C. A client who has a temperature of 38.4° C (101.1° F) and appears confused: Fever and new-onset confusion suggest a possible infection, such as sepsis or urinary tract infection, especially in older adults. This situation indicates a potential life-threatening condition and requires immediate assessment and intervention.
D. A client who had a hip arthroplasty and is requesting pain medication: Managing pain is important, but it is not immediately life-threatening. After addressing the client with fever and confusion, attending to the client's pain needs would be appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Demonstrate to the client how to use the signaling device: Teaching the client how to use the call light is the priority because it ensures they can easily ask for assistance, especially with limited mobility. Immediate access to help reduces the risk of falls, injury, and delays in meeting urgent needs.
B. Explain the facility's meal schedule: While it is important for the client to know when meals are served, this information does not impact their immediate safety or ability to get assistance when needed, making it a lower priority than teaching about the call light.
C. Demonstrate to the client how to use the television: Teaching about the television promotes comfort but is nonessential for safety or urgent needs. Comfort measures can be addressed after critical safety interventions have been completed.
D. Explain the medication administration schedule: Understanding medication schedules is important for client education and adherence, but ensuring the ability to call for help is more immediately critical, especially in a client with limited mobility.
Correct Answer is B
Explanation
A. Temperature of 37.2° C (99.0° F): A temperature of 37.2° C is within the normal range and does not necessarily indicate infection. Mild temperature elevations are common in the immediate postoperative period due to inflammatory responses rather than infection, which typically presents with more significant fever.
B. Elevated WBC count: An elevated white blood cell (WBC) count is a classic and early indicator of infection. It reflects the body's immune response to a bacterial or viral invasion, and postoperative infections often present with leukocytosis, making it a key finding to monitor closely.
C. Pain rating of 4 on a scale of 0 to 10: Moderate pain is expected after surgery and does not, by itself, suggest infection. Postoperative pain should be assessed in context with other symptoms like redness, swelling, or drainage; pain alone, especially if stable, is not definitive for infection.
D. Increased urinary output: Increased urinary output is generally a positive sign of good kidney perfusion and hydration status. A decrease, not an increase, in urinary output would be more concerning postoperatively and could suggest complications, but not necessarily infection.
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