A nurse is reinforcing teaching about a safety plan for a client who reports partner violence. Which of the following instructions should the nurse include?

b. A decreased level of consciousness and vomiting

Explanation:

When receiving report on four clients, the nurse should first collect data about the client who has a decreased level of consciousness and vomiting. This combination of symptoms suggests a potentially serious condition that requires immediate atention and assessment. It could indicate a neurological or gastrointestinal issue, and further evaluation is necessary to determine the underlying cause and provide appropriate interventions.

Explanation for the other options:

a. Cellulitis accompanied by a low-grade fever:

While cellulitis and a low-grade fever require atention, they are not as immediately critical as a decreased level of consciousness and vomiting. The nurse should prioritize assessing the client with altered consciousness and vomiting due to the potential for more urgent interventions.

c. A pain rating of 7 on a scale from 0 to 10 after receiving analgesia 30 min ago:

Although the client's pain rating of 7 indicates ongoing pain, it is not as immediately critical as a decreased level of consciousness and vomiting. The nurse should first address the client with altered consciousness to determine the cause and provide appropriate interventions before assessing and managing pain in other clients.

d. Type 2 diabetes mellitus and a blood glucose level of 160 mg/dL:

While elevated blood glucose levels in a client with type 2 diabetes require atention and management, they are not as immediately critical as a decreased level of consciousness and vomiting. The nurse should first assess the client with altered consciousness to identify the cause and provide prompt interventions.

In summary, when receiving report on four clients, the nurse should first collect data about the client who has a decreased level of consciousness and vomiting. These symptoms indicate a potentially serious condition requiring immediate assessment and intervention.

Answer: A. Pull the auricle upward and outward.

Rationale:

A. Pull the auricle upward and outward:
Pulling the auricle upward and outward is the recommended technique for instilling ear drops in an adult. This method straightens the ear canal, allowing better access for the medication to reach the target area. It is essential for effective delivery and absorption of the otic suspension.

B. Pull the auricle downward and backward:
Pulling the auricle downward and backward is appropriate for children under three years old, as it aligns their shorter and straighter ear canal. In adults, this approach would not straighten the canal sufficiently for optimal medication instillation.

C. Pull the auricle upward and backward:
While pulling the auricle upward and backward can straighten the adult ear canal, the optimal direction to ensure the ear canal is fully open is upward and outward. This position allows the medication to reach deeper parts of the ear canal effectively.

D. Pull the auricle downward and outward:
Pulling the auricle downward and outward is not suitable for adults and does not provide the correct alignment for an adult ear canal. This technique is ineffective in reaching the canal's deeper parts in adult clients, thus limiting the efficacy of the medication.