Safe, Effective Care Environment
24. After receiving an end-of-shift report on four clients, a nurse plans client care. Which client should the nurse assess first?
Safe, Effective Care Environment
24. After receiving an end-of-shift report on four clients, a nurse plans client care. Which client should the nurse assess first?
. Client admitted through the emergency department 3 hours ago with acute abdominal pain.
. Client awaiting discharge and the spouse is at the bedside.
. Client in wrist restraints who has a sitter in the room.
. Client who had a chest tube inserted 24 hours ago for a pneumothorax.
Test-Taking Tip
Start with the client who is most unstable or critical.
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 a newly admitted client with abdominal pain is not stable and is first priority. The cause of the pain is unknown and vital signs should be assessed. Answer 2 is incorrect because the client is going home (fourth priority). Answer 3 is incorrect because the client is being observed by someone and would be third priority. Answer 4 is incorrect because it is important to assess the respiratory status and chest tube functioning soon (second priority).