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 nurse should intervene when the AP tears a document with client information in half before disposing of it in a waste basket. This is because client information is confidential and should be disposed of properly to protect the client's privacy. Tearing a document in half is not sufficient to ensure that the information is protected.
Option A is incorrect because logging off the computer after entering a client's intake and output totals is an appropriate action.
Option C is incorrect because denying a request by another AP to use her password to enter the client's vital signs is an appropriate action to protect the client's information.
Option D is incorrect because removing a clipboard with client information from the room during visiting hours may be necessary to protect the client's privacy.
Correct Answer is C
Explanation
The correct answer is choice C. The nurse does not cause any harm to the client.
Choice A rationale:
While having a license to practice nursing in the state where the event occurred is important for professional practice, it is not a specific requirement for the Good Samaritan law to provide civil immunity.The Good Samaritan law generally protects individuals who provide emergency care in good faith, regardless of their licensure status in that particular state.
Choice B rationale:
Basic life support (BLS) certification is a valuable credential for performing CPR and other emergency procedures. However, the Good Samaritan law does not require the responder to have BLS certification to be protected.The law focuses more on the intent and actions of the responder rather than their specific certifications.
Choice C rationale:
The primary criterion for the Good Samaritan law to provide civil immunity is that the responder does not cause harm to the client.The law is designed to protect those who act in good faith to provide emergency care without gross negligence or willful misconduct. If the nurse’s actions are reasonable and do not result in harm, they are typically protected under the Good Samaritan law.
Choice D rationale:
Remaining with the client when traveling to the hospital in an ambulance is not a requirement for Good Samaritan law protection. The law applies to the immediate emergency care provided at the scene.Once professional medical personnel take over, the Good Samaritan law’s protection generally ends.
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