Which of these clients should the nurse assess first?

Question

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11ecbb05_cbc2_e260_b433_27680c18209c_MD0009_00 First-level priorities include issues of airway, breathing, cardiac and circulation, and vital signs, respectively. A client receiving the first dose of an antibiotic is at risk for allergic reactions, including anaphylaxis. Signs and symptoms of anaphylaxis include itching, flushing, hives, wheezing, bronchospasm, swelling of the oral mucosa, and hypotension. This is a potentially fatal complication that requires immediate intervention (Option C). (Option A) This client with a moderate pleural effusion awaiting the corrective procedure would be the last client to be assessed by the nurse. Shortness of breath is an expected symptom of pleural effusion. If signs or symptoms of respiratory distress or hypoxemia occur, this client will increase in priority. (Option B) This client with a new cast experiencing severe pain would be the second client to be assessed. This client is at risk for compartment syndrome and limb loss. Increasing fluid (eg, bleeding) in a confined space or decreasing compartmental capacity (eg, casting) causes neurovascular compromise as the vessels are compressed and unable to deliver oxygen to the tissues. Long bone fractures account for most cases of acute compartment syndrome. (Option D) This client with sickle cell pain would be evaluated third. Although in crisis, the client is not at risk for loss of life or limb. Educational objective: First-level priorities include issues of airway, breathing, cardiac and circulation, and vital signs, respectively. Anaphylactic reactions are potentially fatal medical emergencies that must be treated immediately. Compartment syndrome prevents perfusion and can cause tissue death and limb loss. Stable clients awaiting procedures are assessed last.

Which of These Clients Should the Nurse Assess first