Management of Care Q 29
During the endorsement, which of the following clients should the on-duty nurse assess first?
A. The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/minute.
B. The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 mm Hg, and a “do not resuscitate” order.
C. The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L.V. heparin.
D. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. diltiazem (Cardizem).
Correct Answer: D. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. diltiazem (Cardizem).
The client with atrial fibrillation has the greatest potential to become unstable and is on L.V. medication that requires close monitoring.
Option A: After assessing the client with thrombophlebitis, the nurse should assess the 58- year-old client admitted 2 days ago with heart failure (his signs and symptoms are resolving and don’t require immediate attention).
Option B: The lowest priority is the 89-year-old with end-stage right-sided heart failure, who requires time-consuming supportive measures.
Option C: Assess this patient next because he is at high risk for developing an emboli, which is fatal.