Question

After the change-of-shift report, the nurse reviews assignments. WHich client should the nurse assess first?

A. The elderly client receiving palliative care for heart failure who complains of constipation and nervousness
B. The adult client who is 48 hours postoperative for a colectomy and who is reported to be having nausea and vomiting
C. the middle-aged client with chronic renal failure whose urinary catheter has been draining 95 mL for 8 hours
D. The client who is 2 days postoperative for a thoracotomy and who has chest tubes, is on oxygen at 3 L/min, and has a respiratory of 12 breaths/min

Answer 1

The nurse should prioritize assessing Client B, the adult client who is 48 hours postoperative for a colectomy and experiencing nausea and vomiting, due to risks of postoperative complications.

Step-by-step explanation:

When prioritizing which client the nurse should assess first after a change-of-shift report, it is crucial to identify which situation poses the most immediate risk to a client's health. The priority should be based on the severity and potential for rapid deterioration.

Out of the four clients described:

• Client A is receiving palliative care for heart failure and complains of constipation and nervousness.
• Client B is 48 hours postoperative for a colectomy and is having nausea and vomiting.
• Client C is a middle-aged individual with chronic renal failure whose urinary catheter has been draining 95 mL for 8 hours.
• Client D is two days postoperative for a thoracotomy, has chest tubes, is on oxygen at 3 L/min, and has a respiratory rate of 12 breaths/min.

Given these options, the nurse should prioritize the assessment of Client B because nausea and vomiting after a colectomy could indicate a potential complication such as an infection or obstruction. This requires immediate assessment and potentially urgent intervention.