Safe, Effective Care Environment
46. A nurse has received an end-of-shift report on four clients. Which client should the nurse see first?
Safe, Effective Care Environment
46. A nurse has received an end-of-shift report on four clients. Which client should the nurse see first?
. A client who is a stockbroker, admitted with GERD, with BP of 160/90.
. A client who is an athlete, admitted with a torn ACL, whose pulse is 57.
. A client who is 78 years old with a temperature of 101°F (38.3°C).
. A client who is post–laparoscopic cholecystectomy, with shoulder pain.
Test-Taking Tip
Look at the vital signs; select the elevated BP. Choose the client who is most unstable, or the condition that puts the client at greater risk.
Content Area: Adult Health, Triage; Integrated Process: Nursing Process, Analysis; 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 correct because the elevated blood pressure may indicate stress or pain, and further assessment is needed to establish why the blood pressure is elevated. Answer 2 is incorrect because a low pulse is common in athletes. Answer 3 is incorrect because this client would not be the first priority. The nurse should see this client second, as the temperature in the older adult may not be an accurate indicator of the client's condition. Answer 4 is incorrect because right shoulder pain or pain in the scapular area are normal and result from the gas used to insufflate the abdominal cavity during the procedure.