While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider (HCP), the nurse should note which of the client’s laboratory values?

Choice A reason: Assessing body temperature monitors for infection but is not specific to vancomycin administration. Clostridium difficile causes fever, but oral vancomycin’s safety depends on renal function, as it is minimally absorbed but can accumulate in renal impairment, making temperature less critical before the first dose.

Choice B reason: Checking serum creatinine is essential, as vancomycin, even orally, can be absorbed in small amounts, risking nephrotoxicity in patients with renal impairment. Clostridium difficile treatment requires ensuring renal function is adequate to prevent drug accumulation, which could exacerbate kidney damage, making this the priority action.

Choice C reason: Measuring oxygen saturation assesses respiratory status, irrelevant to oral vancomycin for Clostridium difficile, which primarily affects the gut. While severe infections may cause systemic symptoms, oxygenation is not a direct concern for vancomycin’s safety or efficacy, making this choice inappropriate.

Choice D reason: Auscultating bowel sounds evaluates gastrointestinal motility, relevant to Clostridium difficile’s diarrheal effects but not vancomycin’s administration safety. Oral vancomycin targets gut bacteria, and bowel sounds do not indicate renal or systemic risks, making this less critical than renal function assessment.

Choice A reason: Escorting the client with Huntington’s disease is best, as chorea and cognitive decline impair navigation and memory. Physical guidance ensures safety, preventing falls or disorientation in unfamiliar hospital settings, directly addressing the disease’s motor and cognitive deficits for effective cafeteria access.

Choice B reason: Orienting to a color-coding system is impractical, as Huntington’s cognitive impairments, like executive dysfunction, hinder processing complex visual cues. This approach overwhelms the client, increasing confusion, and is less effective than physical escorting to ensure safe and direct cafeteria navigation.

Choice C reason: Using a hospital map relies on spatial reasoning, which is impaired in Huntington’s due to basal ganglia degeneration. The client’s cognitive and motor deficits make map-based navigation challenging, increasing disorientation risk, making this less effective than escorting for cafeteria access.

Choice D reason: Step-by-step verbal directions require intact memory and processing, compromised in Huntington’s due to cortical and striatal atrophy. Verbal instructions may confuse the client, leading to navigation errors, making physical escorting a more reliable method to ensure safe cafeteria arrival.