Difficulty: Medium
Average Score: 83%
Simulated
Passage / Scenario
Nurses' Notes0800
Client brought to ED by ambulance from long-term care facility. According to report from long-term care facility RN. client awoke this morning disoriented to time and place, febrile, and incontinent of foul-smelling urine.
0815:
Provider at bedside, prescriptions received.
A nurse is caring for a client in the emergency department (ED).
The nurse should first address the client's __________ followed by the client's __________.
Correct answer
C,D
Rationale
Fall precautions are the immediate priority due to the client's disorientation, which increases fall risk. Antibiotic therapy is secondary to ensure treatment of the likely urinary tract infection indicated by fever and foul-smelling urine.