The nurse has just received shift report. Which client should be seen first?

Question

Quizplus · Accepted Answer

The client with a BKA is experiencing phantom limb pain, pain/tingling felt in a missing portion of a limb. It is real pain that many amputees experience immediately following surgery and that sometimes becomes chronic. This client is rating the pain at a high level on the scale (7 of 10). The nurse should prioritize this client and administer prescribed opiates or other analgesics. (Option A) Because the bowels have been manipulated in AAA surgery, hypoactive sounds are common for several days afterward. (Option C) Bed rest is no longer required for a client with DVT unless the client is having severe edema or leg pain. Early ambulation does not increase the short-term risk of pulmonary embolism, and it can reduce edema and leg pain. The nurse should see this client second to assess the affected limb. (Option D) Raynaud's phenomenon is usually triggered by cold exposure. During a typical episode, digital arteries (most often in the fingers) constrict and blood flow is impaired, causing the skin to turn pale and then blue and to feel numb and cold. As blood flow returns to the affected digits, the skin turns red and a throbbing or tingling sensation is often felt. This is an expected finding; episodes usually resolve in 15-20 minutes once the trigger has been removed (eg, rewarming of the fingers). Educational objective: Phantom limb pain should be prioritized and treated just as any other client report of pain. It is typically treated with opioids early in the post-surgical period. Chronic phantom limb pain may be treated with antidepressants, anticonvulsants, or therapies such as nerve stimulation, mirror therapy, or acupuncture.

The Nurse Has Just Received Shift Report