Question

A nurse has just received report on four clients on a medical-surgical unit. Which of the following clients should the nurse plan to assess first?

A) A client with diabetes who has a blood glucose level of 180 mg/dL
B) A client recovering from hip replacement surgery who reports incisional pain of 4 on a scale of 0 to 10
C) A client with heart failure who has gained 2 pounds in the last 24 hours
D) A client with a history of deep vein thrombosis (DVT) complaining of shortness of breath

Answer 1

The nurse should plan to assess the client with a history of deep vein thrombosis (DVT) complaining of shortness of breath first.

Step-by-step explanation:

The nurse should plan to assess the client with a history of deep vein thrombosis (DVT) complaining of shortness of breath first.

Shortness of breath in a client with a history of DVT could indicate a pulmonary embolism, which is a serious and life-threatening condition requiring immediate medical attention. The nurse should prioritize assessing this client to determine their respiratory status and take appropriate action.

Assessing the other clients is also important, but their symptoms are not as immediately life-threatening as shortness of breath in a client with a history of DVT.