A nurse on an obstetrics-gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse assess first?
A client who is 4 days postpartum and has mastitis
A client who had a bilateral tubal ligation 12 hr previously
A client admitted 1 hr ago for an ectopic pregnancy
A client who is a 1 day postpartum after a late term miscarriage
The Correct Answer is C
Rationale:
A. A client who is 4 days postpartum and has mastitis should be assessed, but this condition is less acute compared to the others.
B. A client who had a bilateral tubal ligation 12 hr previously requires post-operative monitoring, but this is less urgent than the client with an ectopic pregnancy.
C. A client admitted 1 hr ago for an ectopic pregnancy is the priority as this condition can be life-threatening and requires immediate assessment.
D. A client who is 1 day postpartum after a late-term miscarriage requires care, but the immediacy is less than that of the ectopic pregnancy client.
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Correct Answer is A
Explanation
Rationale:
A. Diaphoretic with epigastric pain could be indicative of a myocardial infarction or other severe condition and requires immediate attention.
B. A toddler with a laceration and distress needs care but is not as urgent as potential cardiac issues.
C. An adolescent with slurred speech and belligerence could indicate a neurological issue, but is less immediate than a potential cardiac event.
D. A young adult with a sunburn is painful but not life-threatening compared to other scenarios.
Correct Answer is C
Explanation
Rationale:
A. Reassign the task to another nurse is not immediately necessary; first, the issue needs to be addressed with the LPN.
B. Report the issue to the unit manager should be done if the problem persists, but initial action should involve resolving the immediate issue.
C. Change the client's dressing is essential to address the immediate need and ensure the client’s care is up-to-date.
D. Verify the LPN knows how to do a dressing change might be necessary in the long term, but addressing the immediate issue of the uncompleted task is a priority.