The nurse on the medical unit finishes receiving the change of shift hand-off report at 7:30 AM. Which assigned client should the nurse see first?

Question

Quizplus · Accepted Answer

The nurse should check on the assigned clients in the following order:
Client with the gastrointestinal bleed receiving packed red blood cells (PRBCs) – the nurse should:
Check the infusion device; flow rate; and IV site, tubing, and filter
Collect baseline physical assessment data against which to compare subsequent assessments
Assess for complications associated with the administration of PRBCs, which include fluid overload and an acute transfusion reaction; these can occur at any time during the transfusion (Option A)
Client with chronic kidney disease scheduled for dialysis in 30 minutes - the nurse should perform a baseline assessment before dialysis is initiated.  The nurse should then prepare the client by making sure the client eats breakfast, administering prescribed morning medications that are not dialyzed out, and holding those that are dialyzed out.  Elevated creatinine level (eg, normal 0.6-1.3 mg/dL [53-115 µmol/L]) is an expected finding.  (Option D)
Client with ulcerative colitis (UC) with elevated temperature and abdominal pain – UC is an inflammatory bowel disease; fever and lower-quadrant abdominal cramping are expected findings.  After assessing the client, the nurse will administer an analgesic and an antipyretic as prescribed.  (Option B)
Client with history of atrial fibrillation, prescribed warfarin (Coumadin) – the client is on telemetry; in most facilities, if dysrhythmias occur, the monitor technician/nurse will notify the primary care nurse immediately.  The goal INR is 2.0 to 3.0 for atrial fibrillation.  An INR of 3.2 is expected when adjusting the warfarin dose.  (Option C)
Educational objective:
To prioritize client care, the nurse first identifies the type of problem, its associated complications, and the desired outcomes.  The nurse then decides which client has the most urgent problems and needs and assesses that client first.

The Nurse on the Medical Unit Finishes Receiving the Change