Question

The nurse who is working on a post surgical intensive care unit receives report regarding the assigned clients for the upcoming shift. Which client should the nurse assess first?

a. An adult who has a collapsed lung related to a fall from ladder 8 hours ago and now has 100 mL chest tube drainage.
b. A young adult who had an abdominoperineal resection 3 days ago and is currently complaining of chills.
c. An older adult who had a mastectomy 2 days ago and has 50 mL serosanguinous fluid in the Jackson-Pratt (JP) drain.
d. A teenager who had a gunshot wound repair yesterday and has quarter-size dark drainage on the dressing.

Answer 1

The nurse should assess the adult with a collapsed lung first due to increasing chest tube drainage and the potentially life-threatening nature of the condition.

Step-by-step explanation:

The nurse should assess the adult who has a collapsed lung related to a fall from a ladder 8 hours ago and now has 100 mL chest tube drainage first.

A collapsed lung, also known as a pneumothorax, is a potentially life-threatening condition that requires immediate medical attention. The patient's symptoms indicate a worsening condition, as chest tube drainage is increasing in volume.

Assessing and treating the collapsed lung is the nurse's priority to prevent further complications and provide the necessary support for breathing and recovery.