Question

The nurse on a busy surgical unit has just completed receiving the morning shift report. Which client should the nurse assess first? A. A post-gastrectomy client with \(75 \mathrm{~mL}\) bright red nasogastric drainage in the past hour B. A client receiving total parenteral nutrition following a bowel resection C. A diabetic client with a morning blood glucose of \(210 \mathrm{mg} / \mathrm{dL}\) D. A client with pneumonia receiving intravenous antibiotics

Short answer

Answer: A. A post-gastrectomy client with 75 mL bright red nasogastric drainage in the past hour.

Step-by-step solution

Understand each client's situation

Before making a decision, let's understand the medical issues of each client: A. A post-gastrectomy client with \(75 \mathrm{~mL}\) bright red nasogastric drainage in the past hour: This patient has undergone a gastrectomy and has been experiencing bright red drainage; this might indicate active bleeding. B. A client receiving total parenteral nutrition following a bowel resection: This patient has undergone bowel resection surgery and is receiving nutrients through an intravenous line. C. A diabetic client with a morning blood glucose of \(210 \mathrm{mg} / \mathrm{dL}\): This patient has diabetes and has been tested with a slightly high blood glucose level in the morning. D. A client with pneumonia receiving intravenous antibiotics: This patient has been diagnosed with pneumonia and is receiving treatment through intravenous antibiotics.

Analyze the urgency of each situation

Now, let's analyze the urgency of each client's situation: A. Active bleeding after a gastrectomy requires immediate attention, as it may lead to further complications if not controlled. B. The client receiving total parenteral nutrition is likely stable, especially considering that they are already receiving nutrition through the intravenous line. C. A high blood glucose level in a diabetic client is a concern, but it doesn't usually require immediate attention as it can be managed through insulin administration and/or changes in diet. D. The client with pneumonia is already receiving antibiotics via IV, indicating that their condition is being managed.

Determine which client should be assessed first

Based on the analysis of each situation and the urgency associated, the nurse should assess the client with the most urgent and potentially harmful situation. In this case, it is: A. A post-gastrectomy client with \(75 \mathrm{~mL}\) bright red nasogastric drainage in the past hour. This client is potentially experiencing active bleeding, which requires immediate attention to prevent further complications.

Key concepts

Nursing Priorities

Establishing nursing priorities is crucial to effective patient care, especially in a surgical unit with multiple patients requiring attention. The nurse must swiftly triage each patient based on the urgency of their condition, ensuring those in the most critical state are attended to first. In the case of the nurse who has just received the morning shift report, prioritizing the client with active signs of potential complications, such as bleeding, is paramount.

Nursing priorities often follow the ABCs (airway, breathing, circulation) of medical emergencies, but also consider other urgent factors like acute bleeding or signs of infection. A systematic approach, often guided by protocols such as Maslow's Hierarchy of Needs or the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) assessment framework, can assist nurses in making these critical decisions.

Client Assessment

Conducting a thorough and effective client assessment is key to identifying which patient requires immediate attention. The nurse must collect and interpret data concerning the patients' health status by observing vital signs, reviewing medical history, and understanding recent surgical procedures or treatments. The client presenting with symptoms that may indicate a rapid deterioration in their condition, such as bright red drainage suggestive of active bleeding after a gastrectomy, must be prioritized over less urgent cases.

This process revolves around recognizing changes or abnormalities and determining their potential impact on the patient's overall well-being. The use of a focused assessment approach, in this case, helps in quickly identifying the leading clinical problem that could translate into a life-threatening situation if not addressed swiftly.

Postoperative Care

Postoperative care is a critical component of the nursing responsibilities, particularly for clients who have recently undergone surgery. This period is characterized by the need for close monitoring to prevent, recognize, and respond to potential complications. Key aspects include managing pain, monitoring for signs of infection, ensuring proper wound care, and assessing the functionality of surgical drains.

For instance, in the given scenario, the nasogastric drainage of 'bright red' suggests active bleeding, which is an immediate postoperative care concern that may require rapid intervention to prevent complications such as hypovolemia or shock. Understanding postoperative care norms enables the nurse to differentiate between usual post-surgery symptoms and alarming signs that indicate a deviation from the expected recovery process.