The nurse receives report on 4 clients. Which client conditions require priority assessment?

Question

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Clients who are bedridden, have undergone major surgery (eg, hip or knee replacement), or are taking estrogen-containing contraceptive pills are at high risk of developing deep venous thrombosis. This condition can result in subsequent embolus and life-threatening pulmonary embolism. When blood flow is blocked to certain parts of the lung, the area can become infarcted, resulting in chest pain, shortness of breath, and cough. These clients require immediate anticoagulation to prevent extension of the blood clot. (Option A) Clients with acute pericarditis have chest pain that is worse with inspiration/coughing and improves with leaning forward. This is an expected finding. Large pericardial effusion with resultant cardiac tamponade is more serious and is evidenced by jugular venous distension, hypotension, and muffled heart sounds. (Option B) This client who underwent femoropopliteal surgery likely has acute occlusion of the graft and is at risk of limb loss if flow is not restored. However, loss of life is a priority over loss of limb. (Option D) Atrial fibrillation requires assessment but is not immediately life-threatening in most situations. This client has stable blood pressure and is not the priority. Educational objective: Pulmonary embolism is a life-threatening emergency. Clients who have had major surgery, prolonged immobilization, or are taking estrogen-containing contraceptive pills are at high risk.

The Nurse Receives Report on 4 Clients