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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When preparing to administer medications, the nurse carefully confirms the drug order and the patient's identity. This adherence to an essential ethical principle is Non-maleficence. Non-maleficencerefers to the principle of "do no harm" and requires healthcare providers to avoid causing harm to their patients.
Option A refers to wrongdoing or misconduct and is not applicable in this situation.
Option C refers to truthfulness and honesty, but it is not the primary principle being demonstrated in this situation.
Option D refers to fairness and equality, but it is not the primary principle being demonstrated in this situation.
Correct Answer is ["A","D","E"]
Explanation
The correct answers are Choices A, D, and E.
Choice A rationale:Providing postmortem care to a client who has just passed away is a task that can be delegated to assistive personnel (AP). Postmortem care involves cleaning and preparing the body after death and is not a task that requires the specialized skills or judgement of a nurse. It is important to note that while the physical task of postmortem care can be delegated, the nurse is still responsible for providing emotional support and information to the family, coordinating with the morgue or funeral home, and completing any required documentation.
Choice B rationale:Instructing a client about the use of a spirometer is not a task that should be delegated to assistive personnel. Patient education requires assessment and evaluation of the patient’s understanding, which are nursing responsibilities. A spirometer is a medical device used to measure lung function and is often used after surgery to help prevent complications like pneumonia. Proper use of the spirometer is crucial to its effectiveness, so it is important that the instruction is clear and understood by the patient.
Choice C rationale:Suctioning a client’s newly inserted tracheostomy is not a task that should be delegated to assistive personnel. Tracheostomy care, especially suctioning, requires specialized skills and knowledge, as well as the ability to assess the patient’s respiratory status. Improper suctioning can cause trauma to the trachea, hypoxia, or infection. Therefore, this task should be performed by a nurse or other licensed healthcare professional.
Choice D rationale:Transferring a client to radiology for x-rays is a task that can be delegated to assistive personnel. This task involves physical assistance and does not require specialized nursing skills or judgement. However, the nurse should provide the AP with any necessary information about the patient’s condition, mobility, and any precautions that need to be taken during the transfer.
Choice E rationale:Performing a simple dressing change on a client’s arm is a task that can be delegated to assistive personnel. This task involves changing the bandages on a wound, which is a task that does not require specialized nursing skills or judgement. However, the nurse should ensure that the AP has been properly trained in dressing changes, understands the importance of infection control, and knows when to report any changes in the wound’s appearance.
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