A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first?
a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 ° F (39.1 ° C)
b. Client with Bruton's agammaglobulinemia who is waiting for discharge teaching
c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion
d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia
ANS: A
A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client.
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