The nurse receives a report on the assigned clients for the shift. Which client should the nurse assess first?

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The prioritization principle is that systemic symptoms are more important than local symptoms. Trousseau's sign (carpal spasm with blood pressure cuff inflation) indicates hypocalcemia. This is a known risk after a thyroidectomy as the parathyroid gland can be inadvertently removed during the surgery due to its very small size. Acute hypocalcemia can cause tetany, laryngeal stridor, seizures, and cardiac dysrhythmias. Assessing this client is a priority over pain or expected findings. (Option A) This client likely has postoperative urinary retention and needs to be evaluated as soon as possible (second in priority). Although, this condition is painful and could result in kidney injury, it is not immediately life-threatening. (Option B) This client has isolated systolic hypertension, which is common in elderly clients and they are often asymptomatic. Systolic blood pressure is usually >160 mm Hg but diastolic blood pressure is <90 mm Hg. Treatment might benefit these clients, but this is not a priority. (Option C) ALT and AST are enzymes released when hepatocytes are destroyed as part of the hepatitis pathology. Hepatitis is diagnosed when these enzymes are ≥2-3 times the normal value. The hepatitis C virus usually causes chronic infection. The client's acuity is not directly related to the level of enzymes; this client is not more seriously ill because the enzymes are higher than a client whose labs results are twice the normal value. This is an expected finding and is not a priority. Educational objective: Acute hypocalcemia can be life-threatening due to seizures, tetany (laryngeal stridor), and cardiac arrhythmias. Inadvertent removal of the parathyroid gland can result in rapid development of severe hypocalcemia.

The Nurse Receives a Report on the Assigned Clients for the Shift