High School

A nurse receives a change-of-shift report on 4 clients. Which client should the nurse assess first?

1. Client who experienced a transient ischemic attack 2 days ago and is due to receive scheduled aspirin.
2. Client who had a subdural hemorrhage 36 hours ago and is requesting a breakfast tray.
3. Client with a bowel resection receiving total parenteral nutrition who had 4,800 mL of urine output during the last shift.
4. Client with a stroke receiving tissue plasminogen activator whose Glasgow Coma Scale changed from 9 to 13.

Answer :

Four customers' change-of-shift reports are given to a nurse. The client who had a transient ischemic stroke two days prior and is scheduled to get aspirin [9%] should be assessed by the nurse first. Option 1 is Correct.

A patient with chest discomfort and diaphoresis would be deemed urgent and triaged right away to a treatment area in the emergency department. More stable customers are the others. Analgesics and aggressive intravenous hydration are used to treat vaso-occlusive crises.

Intravenous fluids should be administered in an amount sufficient to reverse dehydration and replace ongoing fluid loss from fever and insensibility. According to the evaluation results, the patient has the following important nursing diagnoses: Acute pain associated with tissue hypoxia brought on by the agglutination of sickled cells within blood vessels. infection danger. Option 1 is Correct.

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