Question

A nurse is receiving afternoon report on four clients who have returned from the PACU this morning. The nurse should assess which of the following clients first?

a. a client who is post-op following a thoractomy has a chest tube with 150 mL bright-red of blood in the collection chamber from the past hour
b. a client who is post-op following a small bowel resection and has a temporary colostomy has absent bowel sounds in all four quadrants
c. a client who is post-op following a tonsillectomy has had one episode of coffee-ground emesis
d. a client who is post-op following a total knee arthroplasty and has a PCA pump is reporting a knee pain level of 7/10

Answer 1

The nurse should first assess the client who is post-op from a thoracotomy with bright-red blood in the chest tube, indicating a possible hemorrhage, which is a potentially life-threatening complication that requires immediate intervention.

Step-by-step explanation:

The nurse should assess the client who is post-op following a thoracotomy first because 150 mL of bright-red blood in the chest tube from the past hour could indicate active bleeding or a hemorrhage, which is a life-threatening emergency. This client's condition takes priority as it can rapidly deteriorate.

The client with an absent bowel sounds post-op from a small bowel resection may be experiencing normal post-operative ileus but is not as immediately urgent as active bleeding. The client who had a tonsillectomy and presents with coffee-ground emesis may experience bleeding complications, but the digested appearance of the blood suggests it is not fresh, reducing its immediacy compared to bright-red blood. Lastly, the client with a total knee arthroplasty experiencing pain needs to be addressed, but this is not as high a priority as an active bleed.

Clinical judgment and prioritization skills are essential for nurses when determining which patient to assess first. They must quickly identify the most acute patient needs and act to ensure patient safety and effective care.