1.The nurse receives report on the medical/surgical unit. Which of the following clients should the nurse see FIRST?
1. A client with an IV of normal saline infusing at 125 ml per hour complaining of slight swelling at the IV insertion site.
2. A client 3 days post right knee replacement complaining of right calf pain with movement.
3. A client with a respiratory rate of 24 and an oxygen saturation of 94% on room air.
4. A client 12 hours after a hysterectomy complaining of nausea.
ANSWER
Strategy: Determine the most unstable client.
(1) assess site for client’s comfort and to prevent complications associated with IV infusion, probable DVT takes priority
(2) CORRECT—assessment for possible DVT should be performed and reported to the physician immediately
(3) respiratory status is stable at present
(4) administer antiemetics; client with calf pain takes priority
A
2
option 2
1
3
2
2
1
1
3
2
4
1