Question

"a nurse is assigned to care for four clients on the medical-surgical unit. which client should the nurse see first on the shift assessment?"

Answer 1

The nurse should see first the client with new-onset of shortness of breath (SOB) and a history of pulmonary edema. The rationale behind this is, in light of such a history, SOB could indicate that fluid-volume overload has once again developed. The client with a fever and who is diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid through the skin, but this client is not the priority. Remember the rule of assessment of the ABCs — airway, breathing, and circulation — which means that the client suffering from SOB should take superiority over the other clients on the unit. This client’s condition could progress to respiratory arrest if the client were not assessed instantly on the basis of the signs and symptoms.