Question

The nurse just received the a.m. shift report. Which client should the nurse assess first?

a. The client diagnosed with CAD who has a BP of 170/100.
b. The client diagnosed with DVT who is complaining of chest pain.
c. The client diagnosed with pneumonia who has a pulse ox reading of 98%.
d. The client diagnosed with ulcerative colitis who has non-bloody diarrhea.

Answer 1

The nurse should first assess the client with DVT complaining of chest pain due to the potential risk of a pulmonary embolism.

Step-by-step explanation:

Considering the a.m. shift report and the information provided about each client, the nurse should assess the client diagnosed with DVT (deep vein thrombosis) who is complaining of chest pain first. This scenario suggests a potentially life-threatening situation like a pulmonary embolism, especially considering the diagnosis of DVT. This takes priority over the client with CAD (coronary artery disease) who has a high blood pressure reading, as the immediate risk of chest pain possibly leading to cardiac arrest is higher. The client with pneumonia and a pulse ox reading of 98% is stable, and the client with ulcerative colitis and non-bloody diarrhea, while needing assessment, does not appear to be in immediate danger.