Safe, Effective Care Environment
12. When an RN returns from dinner break, which client should be assessed first?
Safe, Effective Care Environment
12. When an RN returns from dinner break, which client should be assessed first?
. 82-year-old, 2 days post–total hip replacement with a platelet count of 98,000.
. 28-year-old, IV drug abuser who is 3 days post–aortic valve replacement, with a central line and triple antibiotics due.
. 76-year-old, 1 day post–abdominal aortic aneurysm repair.
. 46-year-old, stable, 4 hours after cardiac catheterization.
Test-Taking Tip
Select the earlier time frame here—hours, not days. Also, look for the client who is most unstable, as indicated by the greatest likelihood of a change in condition.
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
.
Answer 1 is incorrect because there is not an immediate risk to the client from the low platelets. Answer 2 is incorrect because this client is likely stable. Drug withdrawal would have been a concern in the early postoperative period. Answer 3 is incorrect because this client is not in the immediate postoperative period (first 24 hours). This client should be seen second. Answer 4 is correct because there is a risk of bleeding at the insertion site and other postcatheterization complications. Stability of vital signs and ECG need to be assessed.