A nurse working in a long-term care facility is assigned to care for four clients following the 0700 morning change-of-shift report. Which of the following clients should the nurse attend to first?
A client who has bronchitis, began receiving antibiotics yesterday and has a temperature of 38.3°C (101°F).
A client who has COPD and has an oxygen saturation of 90%.
A client who has Alzheimer's and was restless during the night.
A client who has diabetes and had a 0600 blood glucose level of 60 mg/dL.
The Correct Answer is D
Of the four clients described, the nurse should attend to the client who has diabetes and had a 0600 blood glucose level of 60 mg/dL first. This client's blood glucose level is low and requires immediate intervention to prevent further complications.
Option A may require attention, but the client's condition is stable and they are receiving treatment.
Option B may also require attention, but an oxygen saturation of 90% is within an acceptable range for a client with COPD.
Option C may also require attention, but the client's restlessness during the night does not indicate an immediate need for intervention.
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Related Questions
Correct Answer is B
Explanation
The first action the nurse should take is to speak with the other nurse privately. This allows the nurse to address the mistake in a respectful and professional manner and provide guidance on how to perform the procedure correctly in the future.
Option A is incorrect because correcting the mistake independently does not address the underlying issue of the other nurse performing the procedure incorrectly.
Option C is incorrect because volunteering to perform the procedure next time does not address the underlying issue of the other nurse performing the procedure incorrectly.
Option D is incorrect because submitting an incident report may be necessary, but it should not be the first action taken.
Correct Answer is D
Explanation
If a client has received IV morphine sulfate prior to arrival on the unit and is scheduled for surgery, the nurse should delay the procedure. This is because the client may not be able to give informed consent due to the effects of the medication.
Option A may not be appropriate if the client is not able to give informed consent.
Option B is not appropriate as it is not within the nurse's scope of practice to sign consent on behalf of a client.
Option C may be necessary if the client is unable to give informed consent and a relative is available to provide consent.
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