Question

A nurse has received change-of-shift report for a group of clients. Which of the following clients should the nurse assess first?

a. A client who is 1 day postoperative following abdominal surgery and reports pain of 4 on a scale of 0 to 10
b. A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet
c. A client who has atopic dermatitis manifesting with scaling and excoriation of the skin and reports severe itching
d. A client who has pneumonia manifesting with bilateral crackles and diminished breath sounds

Answer 1

The nurse should prioritize the client with pneumonia exhibiting bilateral crackles and diminished breath sounds, following the ABC priority-setting framework. This condition indicates possible respiratory failure and requires immediate assessment and potential intervention.

Step-by-step explanation:

When prioritizing patient care, the nurse must assess the most unstable client first, following the ABC (airway, breathing, circulation) priority-setting framework. In the given scenario, the nurse should assess the client with pneumonia first due to the presentation of breath sounds which could indicate a compromised airway or breathing. Bilateral crackles and diminished breath sounds may signal a worsening condition and the need for immediate intervention to prevent respiratory failure.

While the client asking for a PRN sublingual nitroglycerin tablet following an MI is also concerning, as it suggests ongoing angina, this client already has an established plan of care for chest pain with a PRN medication available. The postoperative client with pain and the client with severe itching due to atopic dermatitis, while needing attention, are not as immediately life-threatening as potential respiratory failure.