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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Assistive personnel (AP), also known as unlicensed assistive personnel (UAP), can perform tasks such as assisting with activities of daily living, hygiene, and nutrition, as well as those tasks that support professional nursing assessments ². Providing postmortem care for a client who has died [d] is a task that can be delegated to an AP.
The other options are not tasks that should be delegated to an AP. Educating a client on the use of a blood glucose monitor [a] involves patient education, which is typically the responsibility of a licensed nurse.
Interpreting a client's vital signs [b] involves assessing the client's health status, which is also typically the responsibility of a licensed nurse. Performing a central line dressing change for a client [c] is a complex task that requires specialized knowledge and skills.
Correct Answer is D
Explanation
The nurse should prioritize the client who requests pain medication as their need is likely the most urgent. Pain management is an important aspect of nursing care and addressing the client's pain should be a priority.
The other clients have needs that are important but not as urgent as the client in pain. The client who wants a bath can wait until the nurse has addressed more pressing needs. The client who asks to review instructions about their new prescription can also wait, as long as they are not in immediate danger. The client who needs a referral for home health services can also wait until the nurse has addressed more urgent needs.
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