Question

"The nurse has responsibility for several clients. Based on the information provided, which of these clients would be a priority for the nurse to evaluate when assuming responsibility for their care at the beginning of the evening shift?

- the 70-year-old client who had a total laryngectomy the previous day
-the 40-year-old client with diabetes who had a fasting blood sugar of 110 mg/dL (6.1 mmol/L)
- an elderly client who has Alzheimer's disease and periods of confusion
- a 20-year-old with a spontaneous pneumothorax who had a chest tube inserted earlier in the day whose vital signs are stable"

Answer 1

The 20-year-old client with a newly inserted chest tube for a spontaneous pneumothorax is the priority for evaluation due to the acute nature of the condition and the potential for rapid, life-threatening changes.

Step-by-step explanation:

The priority client for the nurse to evaluate at the beginning of the shift would be the 20-year-old with a spontaneous pneumothorax who had a chest tube inserted earlier in the day. Although their vital signs are stable, the condition is acute, and any changes in the status of the chest tube or lung re-expansion can quickly lead to life-threatening complications. This client requires close monitoring to ensure the pneumothorax is resolving and that the chest tube is functioning properly. This patient would be a higher priority than the 70-year-old client who had a total laryngectomy the previous day (who would also need to be assessed fairly quickly, but without immediate concerns, it would be less urgent), the 40-year-old client with diabetes who had a normal fasting blood sugar level, and the elderly client with Alzheimer's disease and periods of confusion, assuming they are in a safe environment and their confusion is not acutely worsening.