A client is admitted to the intensive care unit (ICU) with disseminated intravascular coagulation (DIC) associated with a gram-negative infection. Which assessment information has the most immediate implications for the client's care?

Correct Answer: C

Rationale: The correct answer is C) The client's oxygen saturation is 87%. In a client with disseminated intravascular coagulation (DIC) associated with a gram-negative infection, a low oxygen saturation level of 87% indicates hypoxemia, which is a critical situation requiring immediate intervention. Hypoxemia can lead to tissue hypoxia, worsening the coagulation abnormalities in DIC. Therefore, addressing the oxygen saturation level is a priority to prevent further complications. Option A) There is no palpable radial or pedal pulse may suggest impaired circulation but does not address the immediate threat of hypoxemia in this scenario. Option B) The client complains of chest pain is concerning for a possible cardiac event, but hypoxemia takes precedence in the context of DIC and a gram-negative infection. Option D) There is mottling of the hands and feet is indicative of poor perfusion, which is important but not as immediately critical as addressing hypoxemia in this situation. In an educational context, understanding prioritization of care based on the client's condition is crucial for nurses, especially when dealing with complex conditions like DIC. Recognizing and addressing the most critical assessment findings promptly can significantly impact patient outcomes.

Correct Answer: C

Rationale: In this scenario, the correct action to take first is to stop the transfusion (Option C). This is because the client is experiencing signs of a transfusion reaction, specifically a febrile non-hemolytic reaction. This type of reaction is characterized by symptoms such as flushing, chills, fever, and tachypnea, which align with the client's presentation. Stopping the transfusion is crucial to prevent the reaction from worsening and to ensure the client's safety. By halting the transfusion, the healthcare provider can assess the client's condition, confirm the diagnosis of a transfusion reaction, and initiate appropriate interventions. Option A (Obtain a warm blanket for the client) may provide comfort but does not address the underlying cause of the client's symptoms. Checking the client's oral temperature (Option B) could be useful information but is not the priority when a transfusion reaction is suspected. Administering oxygen (Option D) may be necessary if the client develops respiratory distress, but stopping the transfusion takes precedence to prevent further complications. In an educational context, understanding the signs and management of transfusion reactions is essential for nurses and healthcare providers who administer blood products. Rapid recognition and appropriate intervention can mitigate the severity of a reaction and promote positive patient outcomes. It is vital to prioritize patient safety and well-being in these situations by taking prompt and effective actions.

Correct Answer: D

Rationale: In the context of a client admitted with multiple myeloma, the most immediate implication for the client's care is option D) The client is unable to plantarflex the feet. This finding indicates a potential complication of multiple myeloma known as spinal cord compression, which is a medical emergency requiring urgent intervention to prevent permanent neurological damage. Option A) The client complaining of chronic bone pain is a common symptom of multiple myeloma, but it does not indicate an immediate need for intervention. Option B) Elevated blood uric acid levels can occur in multiple myeloma due to increased cell turnover but do not pose an immediate threat. Option C) Bence-Jones protein in the urine is a hallmark of multiple myeloma, but its presence does not require immediate action compared to spinal cord compression. In an educational context, understanding the acute complications of multiple myeloma is crucial for nurses and healthcare providers to prioritize care and intervene promptly to prevent serious consequences for the patient. Recognizing signs of spinal cord compression, such as the inability to plantarflex the feet, can lead to timely assessment, imaging, and treatment to ensure the best outcomes for the client.

Correct Answer: C

Rationale: In this scenario, the best option to delegate to a newly graduated RN with a 6-week orientation to the unit is option C) Infusion of D5.45% normal saline at 125 mL/hour to the client. This task involves a routine and stable procedure that aligns with the RN's level of experience and training. Infusion of fluids is a common nursing responsibility that requires attention to detail but does not involve complex decision-making or critical thinking beyond the scope of a new RN's training. Options A, B, and D involve higher levels of complexity and critical thinking. Option A requires the administration of specific medications with potential side effects and interactions that need careful monitoring and assessment, which is beyond the scope of a newly graduated RN. Option B involves assessing a client for signs of infection, which requires a deeper understanding of GVHD and its complications. Option D requires educating the client about infection prevention, which involves communication skills and a comprehensive understanding of patient education strategies. In an educational context, it is crucial to teach new RNs how to prioritize tasks based on their level of experience and competence. Delegation is a vital skill in nursing that involves assigning appropriate tasks to team members based on their knowledge and skill level. By understanding the rationale behind task delegation, nurses can provide safe and efficient care while promoting professional growth and development.

Correct Answer: D

Rationale: The most important information to communicate to the LTC charge nurse prior to transferring a client with newly diagnosed chronic myeloid leukemia is option D) The client's chemotherapy has resulted in neutropenia. Neutropenia is a critical concern in leukemia patients as it indicates a decreased number of neutrophils, which are important in fighting infections. Leukemia and its treatment compromise the immune system, making patients more susceptible to infections. This information is crucial for the LTC charge nurse to be vigilant about signs of infection and to implement appropriate infection control measures. Option A) The presence of the Philadelphia chromosome in the blood smear is important for diagnosing chronic myeloid leukemia but does not impact immediate care or management at the LTC facility. Option B) Elevated glucose levels due to prednisone therapy may be relevant for managing diabetes but are not as urgent as addressing neutropenia in a leukemia patient. Option C) Weight loss is a common symptom in leukemia, but it does not pose an immediate threat as neutropenia does. Educationally, understanding the priority of communicating critical health information when transferring patients is vital for healthcare professionals to ensure continuity of care and patient safety. This scenario highlights the importance of recognizing and addressing complications of leukemia and its treatment to prevent life-threatening infections in vulnerable patients.