Which client should the nurse assess first?

Question

Quizplus · Accepted Answer

11ecbb05_cbbf_fc2d_b433_2bbf7632c875_MD0009_00 Third-degree atrioventricular (AV) block, or complete heart block, occurs when electrical conduction from the atria to the ventricles is blocked, causing decreased cardiac output (eg, dizziness, syncope, mental status changes, heart failure, hypotension, bradycardia). The client with third-degree AV block is a high priority, as the client may decompensate to cardiogenic shock and even periods of asystole (Option D). Treatment includes administration of atropine and temporary pacing (eg, transcutaneous) until a permanent pacemaker can be placed. (Option A) Atrial fibrillation puts clients at risk for development of atrial thrombi, which can embolize and cause a stroke. Administration of warfarin (a long-term anticoagulant) is important to prevent thrombus formation; however, symptomatic third-degree AV block is a higher priority. (Option B) Clients with chronic obstructive pulmonary disease often have pulse oximetry readings that are lower than normal (eg, 91%). The goal in this client population is to keep the oxygen saturation 88-92%. (Option C) The client experiencing severe postoperative pain should be assessed for surgical complications (eg, infection), and the pain should be treated (eg, with hydrocodone). However, severe pain does not take priority over third-degree AV block. The nurse can see the client as soon as possible or ask another nurse for help. Educational objective: Clients with third-degree atrioventricular (AV) block should be assessed immediately due to the potential for life-threatening consequences (eg, shock, syncope, asystole) caused by decreased cardiac output and severe bradycardia. The client with third-degree AV block requires a permanent pacemaker.

Which Client Should the Nurse Assess first