A nurse is assisting in the care of a group of clients who are postpartum. Which of the following clients should the nurse plan to see first?

Rationale:

• Contact the provider for an antibiotic prescription: Contacting the provider ensures the client receives prompt intervention for a likely surgical site infection. The wound is inflamed and draining yellow pus, and the client has a fever and leukocytosis. Early treatment can prevent the progression to severe sepsis.

• Increase the volume on the television: Increasing the volume on the television can heighten sensory overload and worsen the client’s confusion. Delirium management involves reducing noise and visual stimuli, not adding to it. This approach does not promote orientation or calmness.

• Ask the client's partner to leave the room: Asking the client's partner to leave may remove a critical source of comfort and familiarity. Familiar people help reorient clients with delirium or confusion. Their presence often reduces agitation and promotes emotional security.

• Dim the lights: Dimming the lights reduces environmental overstimulation that may worsen delirium. The client is experiencing hallucinations and disorientation, which are often intensified in bright ICU settings. A calm setting supports cognitive clarity and comfort.

• Assist with elimination: Assisting with elimination is appropriate if the client shows signs of distress or discomfort. However, this need is not emergent compared to infection and altered mental status. Treating the underlying cause of delirium should take precedence.

• Place the client in 4-point restraints: Placing the client in 4-point restraints is a last resort when other safety measures fail. Restraints can escalate agitation and lead to injury or trauma. Delirium should be managed first with environmental and medical interventions.

Rationale:

D. Inspection: This is always the first step in any physical assessment. The nurse observes the abdomen for contour, symmetry, skin condition, and any visible movements or abnormalities.

C. Auscultation: Performed before palpation to avoid altering bowel sounds. Listening to bowel and vascular sounds provides key information about gastrointestinal activity and blood flow.

B. Light palpation: Conducted next to assess for tenderness, guarding, and superficial masses. This helps ensure client comfort and provides a baseline before deeper pressure is applied.

A. Deep palpation: Done last to evaluate organ size, deep masses, or tenderness. It can stimulate peristalsis or discomfort, so it follows the less invasive steps to minimize changes to assessment findings.