Question

After change-of-shift report, which patient should the progressive care nurse assess first?

a. Patient who was extubated this morning and has a temperature of 101.4°F (38.6°C)
b. Patient with bilevel positive airway pressure (BiPAP) for obstructive sleep apnea and a respiratory rate of 16
c. Patient with arterial pressure monitoring who is 2 hours post-percutaneous coronary intervention and needs to void
d. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 101 sec

Answer 1

The nurse should first assess the patient who was recently extubated and has a high fever, as this indicates a potential serious infection and requires immediate intervention.

Step-by-step explanation:

After change-of-shift report, the progressive care nurse should assess the patient who was extubated this morning and has a temperature of 101.4°F (38.6°C) first. This patient displays signs of a potential infection, which is particularly concerning following a procedure like extubation. A high fever can indicate a serious complication, like pneumonia or sepsis, and requires immediate intervention.

The patient with bilevel positive airway pressure (BiPAP) for obstructive sleep apnea and a respiratory rate of 16 is likely stable, given that their respiratory rate is within normal range. The patient with arterial pressure monitoring who is 2 hours post-percutaneous coronary intervention and needs to void might have discomfort but is not in immediate danger. Lastly, the patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 101 sec is also concerning due to potential over-anticoagulation, but the first patient's potential immediate risk likely takes precedence.