The nurse receives the change of shift report for assigned clients at 7 AM. Which client should the nurse assess first?

Question

Quizplus · Accepted Answer

Change in level of consciousness is a high priority problem as it can indicate a neurologic deficit that can be associated with a closed head injury. At the beginning of the shift, the nurse must perform a basic neurologic assessment (eg, pupil size and response, level of consciousness (LOC), mentation, speech, hand grasps). This is done to obtain the baseline data against which subsequent assessments can be compared and to assess for indicators of increased intracranial pressure (eg, change in LOC, Cushing's triad, pupillary changes). (Option B) The client with chronic headaches is scheduled for an MRI in 2 hours. Preparation for the test is not urgent at this time; this client's assessment does not take priority. (Option C) A pulse oximeter reading of 89%-92% is adequate and is an expected finding in a client with COPD who often relies on the hypoxemic drive to breathe. This finding is nonurgent and this client's assessment does not take priority. (Option D) When the heart does not pump effectively, excess fluid in the body develops, blood accumulates in the veins of the legs, and fluid from the capillaries leaks into the interstitial spaces, causing pitting edema. Pitting edema in the lower extremities is an expected finding in a client with heart failure. This is a nonurgent finding and this client's assessment does not take priority. Educational objective: To prioritize client care, the nurse first identifies the type of problem the client has, its associated complications, and the desired outcomes. The nurse decides which client has the most urgent problem or need, and then assesses that client first.

The Nurse Receives the Change of Shift Report for Assigned