Question

The nurse has just received a change-of-shift report. Which client should the nurse assess first? A. A client 2 hours post-lobectomy with 150ccs drainage B. A client 2 days post-gastrectomy with scant drainage C. A client with pneumonia with an oral temperature of \(102^{\circ} \mathrm{F}\) D. A client with a fractured hip in Buck's traction

Short answer

Answer: C. A client with pneumonia with an oral temperature of \(102^{\circ}\mathrm{F}\).

Step-by-step solution

Analyze option A

A client 2 hours post-lobectomy with 150ccs drainage: Since this client has recently undergone a lobectomy and has a significant amount of drainage, they require close monitoring, but they are not necessarily in an urgent situation compared to others.

Analyze option B

A client 2 days post-gastrectomy with scant drainage: This client has undergone a gastrectomy, but since the operation was two days ago and the drainage is scant, the urgency of attending to this client is not high.

Analyze option C

A client with pneumonia with an oral temperature of \(102^{\circ}\mathrm{F}\): This client has a fever due to pneumonia. A temperature of \(102^{\circ}\mathrm{F}\) indicates that the client is experiencing a high fever, and this can be a sign of a severe infection. Monitoring and treating this client is crucial to avoid further complications.

Analyze option D

A client with a fractured hip in Buck's traction: Although this client is experiencing pain due to a fractured hip, they are in Buck's traction, which is aimed at stabilizing the injury and reducing pain. Though they require attention, their condition is stable compared to option C.

Determine the priority

After analyzing each option, it is clear that the client with pneumonia and a temperature of \(102^{\circ}\mathrm{F}\) (option C) requires immediate attention as it can indicate a severe infection and may lead to further complications if not assessed and treated promptly. So the correct answer is C. A client with pneumonia with an oral temperature of \(102^{\circ}\mathrm{F}\).

Key concepts

Patient Assessment

Patient assessment is a crucial initial step in providing effective nursing care. It involves gathering comprehensive information about the patient's current condition and history to identify their healthcare needs. This process helps in the prioritization of care tasks. During assessment, nurses collect data through:

• Direct observation: Noticing visible signs of discomfort, distress, or abnormalities.
• Patient history: Gathering information about past medical procedures and current medication.
• Vital signs: Monitoring essential indicators like temperature, pulse, respiratory rate, and blood pressure.

For example, assessing a post-lobectomy patient with significant drainage requires awareness of potential complications such as infections or fluid imbalance. A systematic approach ensures that urgent issues are identified and addressed promptly.

Postoperative Care

Postoperative care is focused on monitoring and managing a patient’s recovery following surgery. It involves observing for complications, ensuring pain management, and supporting wound healing. Key elements of postoperative care include:

• Checking surgical site drainage for signs of infection or excessive fluid loss.
• Pain management using medications, and assessing pain levels regularly.
• Promoting mobilization to prevent complications like deep vein thrombosis.

Important aspects vary depending on the type of surgery, as seen with lobectomy and gastrectomy patients. For these, complications can be respiratory difficulties or gastrointestinal discomfort, respectively. Ongoing assessment during postoperative care is essential to quickly identify and react to patient needs.

Monitoring Vital Signs

Monitoring vital signs is fundamental in nursing and involves regularly checking a patient’s core health indicators. These signs provide crucial information about the body's basic functions, helping detect early signs of deterioration. The main vital signs include:

• Temperature: Increased temperature can be an early sign of infection.
• Pulse: Changes in heart rate help identify cardiovascular issues.
• Respiratory rate: Indicates breathing effectiveness and potential respiratory issues.
• Blood pressure: Reveals circulatory health and potential for shock.

In the case of the pneumonia patient, a high fever ( 102^{ ext{°}} ext{F}) signals possible worsening infection. Frequent monitoring of these parameters helps nurses make informed decisions and provide timely interventions.

Nursing Decision-Making

Nursing decision-making is the process of evaluating available information to determine the best course of action for patient care. It often involves prioritizing tasks based on the urgency and potential impact on patient outcomes. Nurses rely on several factors to make decisions:

• Severity of condition: Understanding which symptoms indicate more severe issues.
• Speed of intervention: Assessing which conditions require immediate attention to prevent worsening.
• Available resources: Utilizing tools and support effectively to maximize patient care.

In the scenario, the decision to prioritize the pneumonia patient with a high fever over others is a classic example of using critical analysis to determine who needs immediate care. It highlights the need for nurses to balance urgency with the overall wellbeing of all their patients.