Which client does the nurse assess first after receiving morning report?

Question

Quizplus · Accepted Answer

The nurse assesses the client who reports burning at the PCA IV site first. The analgesia runs through a special PCA administration set that is attached to the PCA pump. It is attached to a running IV line, which is on its own infusion pump, to flush the PCA drug through the IV line each time a dose is administered. If the IV line infiltrates the subcutaneous tissue or the catheter becomes occluded, the PCA drug can back up into the primary tubing each time a dose is administered, resulting in inadequate pain control. In addition, burning can indicate phlebitis, which causes vessel wall injury and can lead to thrombophlebitis (Option A). (Option B) The nurse will perform abdominal and pain assessments and will check the function and patency of the suction. However, this client was admitted yesterday, is stable, and does not need to be assessed first. (Option C) An irregular heart rhythm is to be expected in a client with atrial fibrillation, and a heart rate of 94/min is within the normal range (eg, 60-100/min). This client is stable and does not need to be assessed first. (Option D) Incontinence of stool in a client with dementia and C difficile is not uncommon. To provide for immediate client comfort, the nurse can delegate the task of bathing the client to the unlicensed assistive personnel. This client does not need to be assessed first. Educational objective: To prioritize care, the nurse first identifies the type of problem, associated complications, and desired outcomes. The nurse then decides which client problems and needs are most urgent and require immediate action and which can be delayed.

Which Client Does the Nurse Assess first After Receiving Morning