A nurse on the medical surgical unit has just received report. Which client should be seen first?

Question

Quizplus · Accepted Answer

The client with DVT who is experiencing chest discomfort and cough should be seen first. This client is exhibiting possible signs of pulmonary embolism (PE), which can be a life-threatening complication. Signs and symptoms of PE include dyspnea, hypoxemia, tachypnea, cough, chest pain, hemoptysis, tachycardia, syncope, and hemodynamic instability. The nurse should elevate the head of the bed, administer oxygen, and assess the client. The health care provider should be notified of these findings. (Option A) The administration of an IV antibiotic is important but should be done after the nurse has assessed the client with DVT. (Option C) This client is hypertensive and most likely has a headache due to the high blood pressure. The nurse should assess this client after the client with DVT and administer any antihypertensives needed. (Option D) This client can be delegated to unlicensed assistive personnel who can go to the room immediately. Educational objective: The nurse should prioritize the assessment of any client with DVT who is experiencing respiratory signs and symptoms and/or chest pain due to potential development of PE.

A Nurse on the Medical Surgical Unit Has Just Received