A nurse is assisting in monitoring a client who is receiving a tube feeding. Which of the following findings should the nurse identify as the priority?

A. This temperature is slightly elevated (normal range is typically around 36.5-37.5°C or 97.7-99.5°F). While a mild temperature elevation could indicate infection or other underlying issues, it may not be immediately critical unless accompanied by other symptoms such as chills, increased heart rate, or signs of respiratory distress.
B. Hematocrit measures the proportion of red blood cells in the blood. A hematocrit of 45% is within the normal range for adults. However, changes in hematocrit levels over time can indicate fluid balance issues

or nutritional status, which are important to monitor but may not be an acute priority unless significantly abnormal.
C. A respiratory rate of 12 breaths per minute is within the normal range for adults. However, it's essential to consider if this rate is stable or if there are signs of respiratory distress such as increased effort or decreased oxygen saturation. Respiratory status should always be closely monitored, but a normal rate alone is not a priority concern.
D. Urine specific gravity measures the concentration of urine and can indicate hydration status. A specific gravity of 1.015 is within the normal range for urine concentration. However, changes in urine output or specific gravity can provide insights into fluid balance and renal function over time.

A. Clean gloves should be worn when entering the room of a client with MRSA to prevent contact transmission of the bacteria. Gloves should be put on before any contact with the client or potentially contaminated surfaces and should be removed and disposed of properly after leaving the room.
B. A surgical mask is generally not necessary for routine care of a client with MRSA unless there is a risk of splashes or sprays of bodily fluids. The main mode of transmission for MRSA is contact, so gloves are the primary protective measure.
C. Sterile gloves are typically not required unless performing sterile procedures directly involving the wound or handling sterile equipment. For routine assessment of the client's pulse, clean gloves are sufficient.
D. Protective eyewear is not necessary for routine care such as checking a client's pulse. It is primarily used when there is a risk of splashes or sprays that could potentially reach the eyes.