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 4 quadrants
c) A client who is postoperative following a tonsillectomy and has had one episode of coffee-sound emesis
d) A client who is postoperative following a total knee arthroplasty and is reporting a knee pain of 7/10

Answer 1

The nurse should prioritize the client postoperative following a thoracotomy with 150 mL of bright-red blood in the chest tube collection chamber due to the risk of hemorrhage. Other clients have non-life-threatening concerns that can be addressed sequentially.

Step-by-step explanation:

The nurse should assess 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 first. This situation suggests active bleeding, and the client could be at risk for hemorrhage, which is a medical emergency. On the other hand, the other clients present with concerns that are important but not immediately life-threatening: an absent bowel sounds after small bowel resection could indicate a normal postoperative ileus, a single episode of coffee-ground emesis post-tonsillectomy could suggest mild bleeding or stomach irritation, and a knee pain score of 7/10 post-total knee arthroplasty while uncomfortable, is expected and can be managed with pain medication. The primary concern with the thoracotomy patient’s condition is immediate postoperative bleeding which requires swift intervention to prevent further complications.