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

Question

Quizplus · Accepted Answer

This client with altered mental status and not following commands is at risk for aspiration and airway compromise from vomiting. This client should be assessed first; the client needs to be placed in the lateral position with head elevated and may need emergent intubation if airway cannot be protected. (Option A) Clients receiving hemodialysis are at risk for bloodstream infections. Blood cultures need to be obtained from a client with a bloodstream infection, and antibiotics would then be administered. This is not a priority over airway compromise. (Option B) Clients with ankylosing spondylitis often take nonsteroidal anti-inflammatory drugs to control back pain and are at risk of developing gastric ulcers. They can cause melena (black stools). The client needs further assessment of orthostatic vital signs and hemoglobin level. This is not a priority over airway compromise. (Option D) Clients with acute diverticulitis (inflammation of the diverticula) are at risk for perforation, which can be manifested by increasing abdominal pain, rigidity, guarding, and rebound tenderness (peritoneal signs). This client needs further assessment, but this is not a priority over airway compromise. Educational objective: A client with altered mental status and not following commands is at risk for aspiration and airway compromise from vomiting.

The Nurse Receives Report on 4 Clients