Question

A nurse is receiving evening report on four clients who returned from the PACU that morning. Which of the following clients should the nurse assess 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 nurse should first assess the client who underwent a thoracotomy and has a chest tube with 150 mL of bright-red blood in the collection chamber, as this may indicate a life-threatening hemorrhage needing immediate attention.

Step-by-step explanation:

The nurse should prioritize patient assessments based on the severity and potential for rapid deterioration. When deciding which postoperative client to assess first, the nurse should consider the following scenarios:

A. Thoracotomy with chest tube: This client has 150 mL of bright-red blood in the collection chamber from the past hour, which could indicate hemorrhage, a critical and potentially life-threatening situation requiring immediate assessment.

B. Small bowel resection with absent bowel sounds: Absent bowel sounds may occur postoperatively and require monitoring, but this does not indicate an immediate life-threatening condition compared to active bleeding.

C. Tonsillectomy with coffee-ground emesis: Coffee-ground emesis suggests old blood and while it is concerning, it does not indicate recent or active bleeding as much as bright-red blood does.

D. Total knee arthroplasty with pain level of 7/10: Pain management is important after surgery, but severe pain without other signs of complication is not as immediate a threat to life as hemorrhage is.

Considering these factors, the priority is to assess the client who underwent a thoracotomy as the presence of bright red blood may signal a severe complication such as bleeding that could lead to hypovolemic shock.