The nurse receives a hand-off report from the night shift nurse. Which client should the nurse assess first?

Question

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The nurse should assess the client with seizure activity first. This client is at increased risk for injury, aspiration, and airway obstruction. The nurse should obtain baseline neurological vital signs (eg, level of consciousness, pupillary reaction, speech, hand grasps) against which to compare subsequent findings and to evaluate the client's response to lorazepam. The client requires a safe environment, so the nurse should also ensure that fall and seizure precautions (eg, full side rail pads, low bed, floor mats, suction equipment, oxygen at bedside) have been initiated. (Option A) A serious ABO incompatibility/transfusion reaction typically occurs within the first 15 minutes or 50 mL of transfusion. The unit of packed red blood cells was hung 1 hour ago; therefore the baseline 15- and 30-minute vital signs have already been recorded. The nurse will assess the client and infusion rate and site but does not need to check on this client first. (Option B) Hemoglobin of 7 g/dL (70 g/L) is not life-threatening and many clients can tolerate this level. IV iron administration is not a priority. (Option D) The nurse should ensure that the consent form is signed and the client understands the bone marrow biopsy (BMB) procedure, but this client should not be assessed first. BMB is done at the bedside and usually does not have major complications. Educational objective: A client with seizure activity should be assessed as soon as possible after a hand-off report due to increased risk for recurrent seizures, injury, aspiration, and airway obstruction.

The Nurse Receives a Hand-Off Report from the Night Shift