The nurse receives handoff of care report on four clients. Which client should the nurse assess first?

Question

Quizplus · Accepted Answer

The nurse should first assess the client with asthma who reports shortness of breath 15 minutes after receiving a nebulizer treatment with albuterol. Asthma exacerbations may require repeat nebulization every 20 minutes, or continuous nebulization for 1 hour, to relieve severe bronchoconstriction until the administered corticosteroids take effect and start to reduce the inflammation (Option B). The nurse should assess the client for wheezing, decreased breath sounds, use of accessory muscles to breathe, capillary refill, respiratory rate, and pulse oximeter reading and pulse. (Option A) Subcutaneous emphysema is air that leaks into the tissue surrounding the chest tube insertion site. The amount is usually small and reabsorbs spontaneously. The nurse should auscultate for lung sounds, assess for a popping sound, and palpate the site for a crackling sensation. However, this client does not have the most urgent need. (Option C) Clients with an exacerbation of COPD are prescribed noninvasive positive pressure ventilation with a BIPAP device to treat hypercapnia and hypoxemia and improve gas exchange. An oxygen saturation of 88-92% is adequate in clients with COPD. The nurse should perform a thorough pulmonary assessment, but this client does not have the most urgent need. (Option D) The nurse should follow institution policy and either start the IV or notify the IV team to restart the infusion. Although it is important to initiate antibiotic therapy as soon as possible to treat an existing infection, this client does not have the most urgent need. Educational objective: Nurses should prioritize assessing clients with asthma who report unrelieved shortness of breath within 15 minutes of nebulizer treatment with albuterol as their needs are urgent due to the risk for severe pulmonary complications.

The Nurse Receives Handoff of Care Report on Four Clients