Safe, Effective Care Environment
19. Following report on four clients, which client should a nurse assess first?
Safe, Effective Care Environment
19. Following report on four clients, which client should a nurse assess first?
. A client with a chest tube inserted for a spontaneous pneumothorax, with respirations of 18.
. A client with possible acute pyelonephritis. Urine output is 25 mL in the past 2 hours.
. A client 2 days post–radical mastectomy, who is crying and upset.
. A client on reverse isolation who needs pain medication.
Test-Taking Tip
Look for the client who is most unstable.
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 no indication that the client is unstable or experiencing respiratory difficulty. Answer 2 is correct because pyelonephritis is an infectious process that can lead to acute renal failure. If kidney function is inadequate, the client may develop a life-threatening condition, such as hyperkalemia. Answer 3 is incorrect because this response by the client would be a normal reaction to the change in body image. Answer 4 is incorrect because there is no indication that the client is unstable. Pain management is important. However, the client with the inadequate urine output needs further assessment first.