Question

A nurse in a medical-surgical unit is caring for six clients.

Complete the following sentence by using the lists of options.

Nurses' Notes
0800:
Client 1: Client is admitted with a new diagnosis of rheumatoid arthritis.
Client 2: Client has a history of hyperlipidemia. Atorvastatin 20 mg PO administered as prescribed.
Client 3: Client is 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous administered as prescribed.
Client 4: Client is admitted with a new diagnosis of heart failure.
Client 5: Client has a stage 2 pressure injury on the left heel.
Client 6: Client is admitted with a new diagnosis of diabetes mellitus.

Diagnostic Results
0900:
Client 1: C-reactive protein 3.2 mg/dL (less than 1.0 mg/dL)
Client 2: Cholesterol 250 mg/dL (less than 200 mg/dL)
Client 3: Oxygen saturation 88% (95% to 100%)
Client 4: Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L)
Client 5: Prealbumin 14 mg/dL (15 to 36 mg/dL)
Client 6: Glycosylated hemoglobin 8% (less than 7%)


The first client the nurse should assess is
A. Client 1
B. Client 2
C. Client 3

Followed by
A. Client 4
B. Client 5
C. Client 6

Answer 1

The nurse should assess Client 3 first due to reported severe pain and low oxygen saturation levels, which indicate respiratory compromise. Following this, the nurse should assess Client 4, who has a new diagnosis of heart failure and an out-of-range potassium level, which can impact cardiac function.

Step-by-step explanation:

In prioritizing patient care in a medical-surgical unit, the nurse should utilize the ABC prioritization framework (airway, breathing, circulation), along with considering pain and other diagnostic results that indicate urgent issues. According to the given scenarios and diagnostic results, the first client the nurse should assess is Client 3, who reports pain as 8 on a scale of 0 to 10 and has an oxygen saturation of 88%, which is below the normal range of 95% to 100%. This suggests a potential compromise in respiratory function, which requires immediate attention.

Following the assessment of Client 3, the nurse should next assess Client 4, who is admitted with a new diagnosis of heart failure and has a potassium level of 3.2 mEq/L, which is below the normal range. Abnormal potassium levels can affect cardiac function and rhythm, thus posing a significant risk to the client with heart failure and requiring timely intervention.