Assessment of a client two days after surgery reveals a dressing that is dry and intact, temperature 100.2, pulse 90, and blood glucose level of 428. The client requests additional juice or water due to avery dry mouth, and says he is feeling weak and having pain with ambulation. Which of the following isthe nurse likely to consider the highest priority for a change in the plan of care?
a. Elevated blood sugar
b. Dry mouth
d. Elevated temperature
Rationale: Urgency determines the priority in planning care. In this case, theblood sugar is very high, and needs immediate intervention. Pain will need to beaddressed, but other symptoms the client is experiencing may abate once the bloodsugar is in normal range. A slightly elevated temperature is considered normalafter surgery, and with a dressing that is dry and intact, the possibility of infectionis not of the highest priority. There is no indication of the severity of the pain. Thenurse will want to further assess pain after the blood sugar is regulated. Dry mouthis likely a sign of an elevated blood sugar