Safe, Effective Care Environment
42. A nurse is assigned to care for multiple clients who had surgery 2 days ago. Following the 7 a.m. shift report, which client should the nurse assess first?
Safe, Effective Care Environment
42. A nurse is assigned to care for multiple clients who had surgery 2 days ago. Following the 7 a.m. shift report, which client should the nurse assess first?
. A 59-year-old, after a knee arthroplasty, with a WBC of 12,000.
. An 88-year-old, with CHF and post–hip pinning, who was medicated for pain at 0600.
. A 24-year-old, who had a splenectomy at age 18, with a temperature of 38.8°C.
. A 67-year-old, with an abscess post–femur fracture, with a platelet count of 100,000.
Test-Taking Tip
Three of the clients have orthopedic conditions. Choose the only option that concerns a vital organ (spleen). Who is at imminent risk? Think about the stability of the clients. Select the most unstable.
Content Area: Adult Health, Infection Control; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
Safe, Effective Care Environment
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Answer 1 is incorrect because a slight elevation in WBC count is common with the normal inflammation accompanying surgery. No postoperative risks are identified in these data and thus no immediate treatment is required. Answer 2 is incorrect because an elderly client who is postoperative with a history of congestive heart failure (CHF) should be evaluated for response to pain medications and respiratory status, but is not the most critical of the clients described. Answer 3 is correct because bloodstream infections are of great concern in clients without the normal filter of the spleen. The high temperature indicates this client could be septic and will require immediate care with fluids and antibiotics. Answer 4 is incorrect because a platelet count of 100,000, although low, does not put this client at a clinically significant risk of bleeding. Assessment and care of more critical clients should take priority.