Question

A nurse is receiving evening shift report on four clients who returned from the PACU that morning. The nurse should assess which of the following clients first?

a) A client who is postoperative following a thoracotomy and has a chest tube with 150 mL of bright-red blood in the collection chamber from the past 1 hr.
b) A client who is postoperative following a small bowel resection and has a temporary colostomy along with absent bowel sounds in all four quadrants.
c) A client who is postoperative following a tonsillectomy and has had one episode of coffee-ground emesis.
d) A client who is postoperative following a total knee arthroplasty and is reporting a pain level of 7 on a scale from 0 to 10.

Answer 1

The client with a thoracotomy and chest tube showing 150 mL of bright-red blood in the collection chamber should be assessed first as it indicates active bleeding, a life-threatening condition requiring immediate attention.

Step-by-step explanation:

The nurse should assess the client with the thoracotomy and chest tube first. The presence of 150 mL of bright-red blood in the collection chamber from the past hour indicates active bleeding and can quickly lead to hemodynamic instability or hypovolemic shock. This is a life-threatening condition and requires immediate attention.

In comparison, the absence of bowel sounds after a bowel resection and colostomy, coffee-ground emesis after tonsillectomy, and pain after knee arthroplasty, while important, are not as immediate life-threatening as significant bleeding post-thoracotomy. Although each client needs to be assessed and monitored carefully, prioritizing care is crucial in a situation where the patient's life could be at immediate risk.