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

Question

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The nurse should first assess the client showing symptoms of a deep venous thrombosis (DVT) (eg, unilateral edema, warmth, redness, tenderness on palpation). DVT is a postoperative complication related to venous stasis and subsequent thrombosis. If a DVT is suspected, early diagnostic testing (eg, venous ultrasound) and treatment with anticoagulant therapy (eg, heparin, enoxaparin) are critical to prevent clots from traveling to the pulmonary circulation and causing pulmonary embolism. (Option A) The client is experiencing a common post laparoscopic cholecystectomy problem of referred pain to the right shoulder. Carbon dioxide, used to inflate the abdominal cavity during surgery, causes irritation to the phrenic nerve and diaphragm, which may cause difficulty breathing. Interventions for alleviation include the Sims position, deep breathing, ambulation, and analgesics. (Option B) A small amount of pink serosanguineous drainage at the new tracheostomy site is expected postoperatively. The nurse should notify the health care provider if bleeding becomes excessive. (Option D) Conditions that increase the likelihood of surgical site infection include obesity, immunosuppression, malnutrition, diabetes, and advanced age. The nurse should notify the health care provider of signs and symptoms of infection (eg, fever, purulent drainage), but the client with a DVT is priority due to the risk of pulmonary embolism. Educational objective: Assessing the client with a possible deep venous thrombosis is the priority due to life-threatening risk of pulmonary embolism. Characteristic manifestations of deep venous thrombosis include calf pain, unilateral edema, warmth, redness, and tenderness on palpation.

The Nurse Receives Report on 4 Assigned Clients