Question

A nurse is receiving change-of-shift report. Which of the following clients should the nurse assess first?

Option 1: A client who has a WBC count of 15,000/mm3 and is receiving antibiotics.

Option 2: A client who had abdominal surgery 6 hr ago and has had a heart rate of 120/min for the last 2 hr.

Option 3: A client who is requesting pain medication 24 hr after an open reduction and internal fixation (ORIF) of the left ankle.

Option 4: A client who has pneumonia and an oxygen saturation of 95% and is refusing prescribed medication.

Answer 1

The nurse should prioritize the client who had abdominal surgery 6 hr ago with a heart rate of 120/min because it suggests possible postoperative complications needing immediate attention.

Step-by-step explanation:

The nurse should assess the client who had abdominal surgery 6 hr ago and has had a heart rate of 120/min for the last 2 hr first. This is because a heart rate persistently higher than 100 beats per minute (tachycardia) following surgery could indicate complications such as hemorrhage or hypovolemia (decreased blood volume). The urgency is even greater considering the patient's surgery involved the abdomen, where significant internal bleeding can occur postoperatively. Immediate assessment is crucial for timely intervention.

While elevated WBC count and requests for pain medication are important, they don't generally require the same immediacy.

A patient with pneumonia who has an oxygen saturation of 95% and is refusing medication does require intervention but is currently stable. Therefore, the immediate priority is the patient with potential signs of postoperative hemorrhage or other complications, as the increased heart rate could quickly lead to deterioration if not addressed.