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. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate is a priority to ensure the safety and proper positioning of a vulnerable postoperative patient.
B. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma can be done later, as it is not as critical as ensuring the safety of a postoperative infant.
C. Collect a stool sample for ova and parasites from a school-age child is important but not as urgent as checking restraints for a postoperative infant.
D. Engage a toddler in play is important for developmental support but is not as urgent as tasks directly related to patient safety and postoperative care.
Correct Answer is D
Explanation
Rationale:
A. A client who has a small circular partial-thickness burn of the left calf requires care, but this is less urgent compared to severe airway or respiratory issues.
B. A client who has a massive head injury and is experiencing seizures is critical but still less urgent compared to immediate life-threatening airway issues.
C. A client who has a splinted open fracture of left medial malleolus requires care but is not as immediately life-threatening as respiratory issues.
D. A client who has severe respiratory stridor and a deviated trachea has a life-threatening airway obstruction that needs immediate intervention to ensure adequate breathing and oxygenation.