A nurse in a medical-surgical unit is caring for six clients. The nurse needs to assess the clients based on their conditions.

Exhibits

Based on the Nurses’ Notes, which client should the nurse assess first? Please select the correct client number from the choices below:

The correct answer is Choice C.

Choice C rationale: Assessing the patient for orthostatic hypotension is crucial because patients who can only bear weight on one leg may have compromised balance and stability. Orthostatic hypotension, or a sudden drop in blood pressure upon standing, could lead to dizziness or fainting, increasing the risk of falls and injury. Identifying this condition before transferring the patient ensures appropriate interventions can be taken to maintain safety and prevent accidents. The nurse can then apply necessary precautions such as additional support or slow, gradual position changes to minimize the risk.

Choice A rationale: Rocking the patient up to a standing position might help initiate the transfer, but it’s not the immediate priority after securing a safe environment. Ensuring the patient's stability and monitoring their vital signs, especially for orthostatic hypotension, is essential before attempting any movement.

Choice B rationale: Pivoting on the foot that is the farthest from the chair is part of the transfer technique, but it should only be performed after confirming the patient is stable and not at risk of orthostatic hypotension. Proper assessment precedes this step to prevent potential falls.

Choice D rationale: Applying a gait belt to the patient is important for safe transfer, but again, this step follows the assessment of the patient's condition. The gait belt is an aid for the transfer process, but its effectiveness relies on the patient's ability to stand without becoming dizzy or faint.

Choice A rationale: Client 1 is admitted with a new diagnosis of rheumatoid arthritis. While this condition can cause discomfort and requires management, it is a chronic condition that does not typically present an immediate threat to the client’s health. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their new diagnosis, they are not the highest priority at this time.

Choice B rationale: Client 2 has a history of hyperlipidemia and has been administered Atorvastatin 20 mg PO as prescribed. Hyperlipidemia is a chronic condition that requires ongoing management, but it does not typically present an immediate threat to the client’s health. The fact that the client has been administered their medication as prescribed suggests that their condition is currently being managed effectively. Therefore, while this client will need to be monitored to ensure that their medication continues to be effective, they are not the highest priority at this time.

Choice C rationale: Client 3 is 1 day postoperative and reports pain as 8 on a scale of 0 to 10, even after Morphine 5 mg subcutaneous was administered as prescribed. This indicates that the client’s pain is not well controlled and could be a sign of complications. Therefore, immediate assessment is required. This client should be the nurse’s highest priority.

Choice D rationale: Client 4 is admitted with a new diagnosis of heart failure. Heart failure is a serious condition that can have life- threatening complications. However, the fact that this is a new diagnosis suggests that the client’s condition is not yet severe enough to require immediate intervention. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their new diagnosis, they are not the highest priority at this time.

Choice E rationale: Client 5 has a stage 2 pressure injury on the left heel. Pressure injuries can lead to serious complications, including infection and tissue necrosis. However, a stage 2 pressure injury is a relatively minor injury that is unlikely to present an immediate threat to the client’s health. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their pressure injury, they are not the highest priority at this time.

Choice F rationale: Client 6 is admitted with a new diagnosis of diabetes mellitus. Diabetes is a chronic condition that requires ongoing management. However, the fact that this is a new diagnosis suggests that the client’s condition is not yet severe enough to require immediate intervention. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their new diagnosis, they are not the highest priority at this time.