The nurse receives report on 4 clients. Which client should the nurse see first?

Question

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The nurse should assess the postoperative client first by monitoring vital signs, examining the dressing and amount and appearance of the drainage, and performing a neurovascular assessment (eg, pulses, skin color and temperature, sensation, movement). Serosanguineous (pink) drainage would be expected 2 hours after surgery, but a dressing saturated with sanguineous (bright red) drainage indicates excessive blood loss with possible hemorrhage; it should be reported immediately to the health care provider for evaluation. A pressure dressing may be required to provide wound hemostasis, or the client may need to return to the operating room for cauterization of a bleeding vessel. This client is at highest risk for morbidity and mortality (Option A). (Option B) The dressing on an infected foot ulcer is usually removed before the foot is placed in a whirlpool bath (hydrotherapy). The nurse can apply a new dressing or cover and wrap the foot using a sterile towel or gauze bandage to protect it from microorganisms. This client is not the priority. (Option C) Dialysis grafts are prone to infection. This client needs to be assessed for erythema, graft tenderness, fever, and tachycardia. These are not immediately life-threatening conditions. (Option D) Infection can cause delirium (altered mental status). This client needs one-to-one observation and repeated reorientation while antibiotics take effect. However, this client is not a priority over a client who is actively bleeding. Educational objective: Serosanguineous (pink) drainage is expected after a surgical procedure, but a dressing saturated with sanguineous (bright red) drainage indicates excessive blood loss with possible hemorrhage; it should be reported immediately to the health care provider for evaluation. Treatment with a pressure dressing to provide hemostasis, cauterization of a bleeding vessel, or fluid replacement may be necessary.

The Nurse Receives Report on 4 Clients