The nurse receives report on 4 clients. Which client should the nurse assess first?

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11ecbb05_cbc4_de31_b433_4148c7df0f5d_MD0009_00 The client with pneumonia and asthma is at risk for problems related to airway management and should be assessed first. Clients with symptomatic asthma will receive inhaled beta agonists (eg, albuterol); however, even after medication, it is a priority to assess this client's lung sounds, work of breathing, and level of consciousness to determine respiratory status. A sudden decrease in wheezing may signal the development of silent chest, where airflow is rapidly reduced due to increased bronchial constriction. This scenario can quickly progress to status asthmaticus, respiratory failure, unconsciousness, and death. (Option A) Unresolved pain should be reassessed by the nurse, but a client with a possible respiratory emergency takes priority. (Option B) Shortness of breath with activity is expected in a client with chronic kidney disease and anemia. This is most likely due to lack of erythropoiesis (red blood cell production) related to decreased erythropoietin production in the kidney and does not require immediate attention. (Option C) Dilutional hyponatremia (<135 mEq/L (135 mmol/L) is expected in a client with heart failure due to excess fluid and can cause fatigue and headache. Change in level of consciousness and seizures can occur with sodium <120 mEq/L (120 mmol/L), but a borderline low level does not require immediate attention. Educational objective: After receiving report, the nurse should assess clients with airway and respiratory problems first (eg, airway, breathing, circulation). The client with asthma may have silent chest (sudden decrease in wheezing related to severe decrease in airflow) and require immediate attention.

The Nurse Receives Report on 4 Clients