Question of The Day

Which client should the cardiac nurse assess first after receiving the p.m. shift
report?

1. The client who is completing the second unit of PRBCs.
2. The client who is crying after being informed of a terminal diagnosis.
3. The client who refused to eat the dietary tray but got food from home.
4. The client who became short of breath ambulating in the hallway

Write your answer in the comment section.

 1. This client is being treated, and if the blood

is almost finished, then it can be assumed

that the client is tolerating the blood without

incident.

2.CORRECT. The client has been given devastating

news. When all the information in the

options is expected and not life threatening, then psychological issues have priority. This client should be seen first.

3. The client has eaten. The nurse could

arrange for the dietician to consult with 

the client about food preferences, but this

client does not need to be assessed first.

4. Dyspnea on exertion is not priority if the

client is exerting himself or herself.

Content – Medical/Surgical: Category of Health 

Alteration – Cardiovascular: Integrated Processes –

Nursing Process: Assessment: Client Needs – Psychosocial

Integrity: Cognitive Level – Analysis

MAKING NURSING DECISIONS: The test taker

must determine if the assessment data is normal

or abnormal for the client’s diagnosis or situation. If the data is abnormal then this client

should be seen first. If the data is normal then a

client with a psychosocial problem is the client

the nurse should assess first.