The nurse has just received the change of shift report and is preparing to make rounds. Which client should the nurse assess first?

A. A client recovering from a stroke with an oxygen saturation rate of 99%

B. A client three days post-coronary artery bypass graft with an oral temperature of 100.2 degrees Fahrenheit

C. A client admitted one hour ago with rales and shortness of breath

D. A client being prepared for discharge following a right colectomy

Question

14-01-2025
Medicine

College

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The nurse has just received the change of shift report and is preparing to make rounds. Which client should the nurse assess first?

A. A client recovering from a stroke with an oxygen saturation rate of 99%

B. A client three days post-coronary artery bypass graft with an oral temperature of 100.2 degrees Fahrenheit

C. A client admitted one hour ago with rales and shortness of breath

D. A client being prepared for discharge following a right colectomy

Answer :

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anuragpalchoudhury19 anuragpalchoudhury19 · Answer 1 · 2024-01-18T01:04:32-05:00

Final answer:

The nurse should prioritize the client showing signs of acute respiratory distress, such as rales and shortness of breath, due to the immediate life-threatening nature of their condition. Therefore, the correct answer is C. A client admitted one hour ago with rales and shortness of breath.

Explanation:

The nurse should assess the client admitted one hour ago with rales and shortness of breath first. This client's symptoms are indicative of acute respiratory distress which could be due to conditions such as pneumonia or heart failure. Respiratory distress is a life-threatening condition that requires immediate intervention to preserve life and prevent further deterioration. In contrast, a client with a slightly elevated temperature after surgery, a client with an excellent oxygen saturation recovering from a stroke, and a client being prepared for discharge, although important, do not present with symptoms that are immediately life-threatening.