A nurse is caring for four clients. Which of the following clients should the nurse assess first?
A client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness
A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL
A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10
A client who is 3 days postoperative following abdominal surgery and is ready for discharge
The Correct Answer is A
a. The client with Alzheimer's disease and bacterial pneumonia experiencing newly onset restlessness may indicate a change in their condition, such as worsening infection or delirium, which requires immediate assessment and intervention to address their underlying medical needs.
b. While hyperglycemia in a newly admitted client with diabetes mellitus is concerning, it does not typically require immediate assessment unless accompanied by signs of diabetic ketoacidosis or other acute complications.
c. Although the client postoperative from hip fracture reduction reporting a pain level of 7 requires attention, it is not as urgent as assessing the client with newly onset restlessness, which may indicate a more acute issue.
d. The client who is 3 days postoperative and ready for discharge does not require immediate assessment compared to the client with newly onset restlessness, whose condition may be deteriorating.
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Correct Answer is D
Explanation
a. While limited social support is important to address for a successful discharge plan, it may not be as urgent as addressing issues directly related to the client's recovery from surgery.
b. Decreased self-esteem is a significant concern but may not directly impact the client's immediate postoperative recovery and discharge plan.
c. Inadequate food supply is important to address for the client's overall well-being but may not be as urgent as addressing issues directly related to the client's recovery from surgery.
d. Low pain tolerance can significantly affect the client's recovery process and may require immediate attention to ensure adequate pain management postoperatively.
Correct Answer is C
Explanation
a. Green tags are used for the "walking wounded" who will need medical care at some point after more critical injuries have been treated. This would not be appropriate for a client with full thickness burns on 72% of his body, as this condition is life-threatening and requires immediate attention.
b. Yellow tags are for those who require observation and possible later re-triage. Their condition is stable for the moment, and they are not in immediate danger of death. This client's condition, however, is too critical for a yellow tag.
c. Black tags are typically used for individuals who are deceased or expected to die imminently. The chances of survival for this patient are very minimal since the burn surface area is more than 50% with full thickness burns
d. Red tags are for those with severe injuries who require immediate treatment but have a chance of survival.
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