15. A nurse receives a change-of-shift report from the previous primary nurse at 7 a.m. Which client should the nurse assess first?
1) A client receiving an intravenous infusion at 75 hour and has 200 left in the bag
2) A client who had a pacemaker inserted the day before and is being monitored via telemetry
3)A client who had an asthma attack and was medicated with a bronchodilator 30 minutes ago
4) A client who had a total knee replacement 2 days ago and is receiving continuous passive range of motion to the affected leg
The client who had a pacemaker inserted the day before and is being monitored via telemetry should be assessed first.
To determine which client the nurse should assess first, it is important to prioritize based on the urgency of their conditions. Here is a step-by-step approach to help prioritize:
Step 1: Assess the urgency of each client's condition:
- Client 1: A client receiving an intravenous infusion at 75 ml/hour and has 200 ml left in the bag.
- Client 2: A client who had a pacemaker inserted the day before and is being monitored via telemetry.
- Client 3: A client who had an asthma attack and was medicated with a bronchodilator 30 minutes ago.
- Client 4: A client who had a total knee replacement 2 days ago and is receiving continuous passive range of motion to the affected leg.
Step 2: Prioritize based on the potential risks or complications associated with each condition:
- Client 1: The remaining 200 ml in the intravenous bag may not be an immediate concern as it can be monitored and addressed later.
- Client 2: A client with a recently inserted pacemaker may be at risk for complications or sudden changes in heart rhythm that need immediate assessment.
- Client 3: A client who recently had an asthma attack and received medication may need monitoring to ensure the effectiveness of the treatment and evaluate their respiratory status.
- Client 4: A client who had a total knee replacement 2 days ago and is undergoing passive range of motion exercises may require ongoing assessment, but their condition is likely less urgent compared to the previous clients.
Step 3: Determine the client who requires immediate assessment:
Based on the urgency and potential risks associated with each condition, the nurse should assess Client 2, who had a pacemaker inserted the day before and is being monitored via telemetry. This is because changes in heart rhythm or possible complications related to the pacemaker insertion need immediate attention from the nurse.