Question

The nurse sees clients in the medical-surgical unit. Which client does the nurse see first?

1. A client diagnosed with heart failure and who has received 800 mL of IV fluids in 2 hours.
2. A client diagnosed with lung cancer with a blood calcium level of 10.5 mg/dL (2.63 mmol/L).
3. A client diagnosed with hypertension and who requires the 0900 dose of captopril.
4. A client postoperative after a laminectomy and who requires supervision when ambulating.

Answer 1

The nurse in the medical-surgical unit should see the heart failure patient who received 800 mL of IV fluids in 2 hours first, as they are at high risk for acute pulmonary edema, a life-threatening condition.

Step-by-step explanation:

In the medical-surgical unit, the nurse must assess and prioritize patient care based on the severity and immediacy of patients' conditions. Upon reviewing the scenarios, the nurse should see the client diagnosed with heart failure who has received 800 mL of IV fluids in 2 hours first. This patient is at risk for fluid overload and subsequent acute pulmonary edema, which can be life-threatening given their heart failure diagnosis.

The client with lung cancer and a blood calcium level of 10.5 mg/dL (2.63 mmol/L) does not exhibit immediate life-threatening conditions since this calcium level is within the normal range. The client requiring the 0900 dose of captopril for hypertension should be seen according to their medication administration schedule, and while timely, this does not take precedence over more acute situations. The postoperative client after a laminectomy requiring supervision when ambulating poses a risk for falls; however, this does not require immediate attention over the heart failure patient with potential fluid overload.