Question

A nurse is receiving evening shift reports on four clients who returned from the PACU that morning. The nurse should assess which of the following clients first. Option 1: 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.

Option 2: A client who underwent knee arthroscopy and has mild swelling at the surgical site.
Option 3: A client who had a laparoscopic cholecystectomy and reports abdominal pain rated at 4 on a scale of 0 to 10.
Option 4: A client who had a hernia repair and has a temperature of 100.4°F (38°C).

Answer 1

The nurse should assess the 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. This indicates active bleeding, which is a critical condition that requires immediate assessment.

Step-by-step explanation:

The nurse should assess the 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. This client's situation indicates active bleeding, which is a critical condition that requires immediate assessment. Bright-red blood in the chest tube suggests arterial bleeding, which can rapidly lead to hypovolemic shock if not addressed promptly.