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 thoractomy and has a chest tube with 150 mL of bright-red blood in the collection chamber from the past 1 hr.
B)Determine if the client's faith conflicts with the treatment plan

Answer 1

The nurse should prioritize the client with a chest tube showing 150 mL of bright-red blood, suggesting active bleeding and possible complications post-thoracotomy.

Step-by-step explanation:

The nurse should assess the client who is postoperative following a thoractomy and has a chest tube with 150 mL of bright-red blood in the collection chamber from the past 1 hr first. This is indicative of active bleeding and could be life-threatening, representing a potential medical emergency. The surgical team including the surgeon, nurse, and anesthesia professional emphasize the importance of reviewing aloud key concerns for the recovery and care of the patient, which includes critical and unexpected steps, operative duration, anticipated blood loss, concerns specific to the patient, and confirmation of equipment availability and sterility.