Who do you see first

Question 1

A nurse is admitting a client with a tumor in the lumbar spine. Which problem should the nurse assess for first?

Accepted Answer

A: Urinary retention. The type of tumor matters less here than where it sits. A lesion in the lumbar spine presses on the lumbar roots, and the lumbar roots supply the bladder and the legs.

So the first assessment is the bladder. Ask when the client last passed urine, feel for a distended bladder above the pubic bone, and scan it if a scanner is available. Retention is silent in a client whose sensation is already altered, and a bladder can hold well over a liter before anything obvious shows.

Leg function is the second assessment and it comes straight after. The same reasoning applies whatever put the pressure there, whether that is a tumor, an abscess, a disc or an operation. The level guides the assessment.

Question 2

At 0200, four clients are waiting to be seen in the women's health area of the emergency department. Which client should the nurse see first?

Accepted Answer

C: A 29-year-old client at 7 weeks of gestation who reports sudden sharp pelvic pain and new right shoulder pain. Sudden sharp pelvic pain in early pregnancy followed by shoulder pain suggests a ruptured ectopic pregnancy. Blood in the peritoneal cavity irritates the diaphragm, and the pain is referred to the shoulder. A ruptured tube can bleed heavily and cause hemorrhagic shock within minutes, so this client is seen first and assessed for hypotension, tachycardia and signs of poor perfusion.

Question 3

The nurse is caring for four clients on a pulmonary-oncology unit. After hand-off report, which client should the nurse see first?

Accepted Answer

D: A client with emphysema who has sudden, sharp right chest pain and SpO2 of 82%. Sudden, sharp chest pain on one side with a drop in SpO2 in a client with emphysema points to a spontaneous pneumothorax. Overdistended alveoli can merge into large air spaces (bullae) that rupture and let air into the pleural space, collapsing part of the lung. The client has little lung reserve, so this can quickly become life threatening. The nurse assesses breath sounds and vital signs, raises the oxygen as needed and notifies the health care provider right away.

Question 4

A client's membranes ruptured 20 hours ago and she is in early labor. Which assessment is the priority for the nurse?

Accepted Answer

A: The maternal temperature and the fetal heart rate. The length of time the membranes have been ruptured is the single biggest determinant of infection risk in labor, and 20 hours is long. The barrier between the vagina and the uterus has been open all that time.

So the two things watched are the maternal temperature and the fetal heart rate, because those are where the infection shows itself first, and the fetal rate often moves before the temperature does. Both are checked more often than they would be otherwise.

The practical measures that go with it matter too: limiting vaginal examinations, because each one carries organisms upward, and watching the fluid for a change in color or smell.

Question 5

The nurse receives report on four clients on a medical-surgical unit. Place the clients in the order the nurse should see them.

Accepted Answer

1: A client with asthma who has an oxygen saturation of 90% and is using the neck muscles to breathe; 2: A client 1 day after a bowel resection who rates incisional pain 7 of 10 and last had analgesia 5 hours ago; 3: A client with deep vein thrombosis on a heparin infusion whose latest aPTT is within the target range; 4: A client with pneumonia who is going home today and is waiting for discharge teaching. The asthma client is first. An oxygen saturation of 90% with accessory muscle use is a breathing problem that can get worse quickly, and it outranks everything else by airway and breathing.

The postoperative client is second. Pain of 7 of 10 after a bowel resection is expected, but it is not controlled and the last dose was 5 hours ago. Unrelieved pain keeps the client from deep breathing and walking, which raises the risk of pneumonia and clots.

The heparin client is third. The aPTT is in range and the client is stable, so the nurse checks for bleeding during the routine assessment.

The discharge client is last. The client is stable and the teaching can be done once the others are seen.

Question 6

The nurse in a newborn nursery has just received the shift report. Which newborn should the nurse assess first?

Accepted Answer

D: A 6-day-old with foul-smelling redness spreading from the cord onto the abdomen. Redness spreading out from the base of the cord onto the abdominal skin, with a foul smell, is omphalitis, a bacterial infection of the umbilical stump. In a newborn it can spread quickly to the abdominal wall, the blood and the liver, and it can be fatal. This newborn needs assessment now, including temperature, feeding and alertness, and prompt antibiotics.

The other three findings are normal. Bluish hands and feet with a pink trunk is acrocyanosis, common in the first day or two. The white, creamy material is vernix, which protects the skin and is left to absorb. A dry, darkening stump is exactly how the cord should look as it separates.

Question 7

After the morning report on an oncology unit, the nurse reviews the needs of four clients. Which client requires the nurse's attention first?

Accepted Answer

D: A client whose platelet count is 9,000/mm3 and who has a headache with new confusion. A platelet count of 9,000/mm3 carries a high risk of spontaneous bleeding, and a new headache with new confusion can mean bleeding inside the skull. An intracranial bleed can enlarge quickly and is life-threatening. The nurse sees this client first, performs a neurological assessment and notifies the provider at once, anticipating a CT scan of the head and a platelet transfusion.

Question 8

The nurse in a women's health clinic has four telephone messages from clients who take combined oral contraceptives. Which client should the nurse call back first?

Accepted Answer

A: A 30-year-old client with new pain and swelling in the left calf since last night. Estrogen in combined pills raises the risk of venous thromboembolism. One-sided calf pain and swelling suggest deep vein thrombosis, one of the ACHES warning signs, and a clot can travel to the lungs. This client needs to stop the pill and be seen the same day for evaluation, often with a venous ultrasound.

Question 9

At the start of a night shift, the nurse on a medical unit receives report on four clients. Which client should the nurse see first?

Accepted Answer

A: A client in a soft wrist restraint whose fingers on that hand are pale and cool, with a capillary refill of 4 seconds. Pale, cool fingers with slow capillary refill in a restrained limb mean the strap is cutting off circulation. This is an actual, current threat to tissue, and the nurse must loosen or remove the restraint and assess the hand now. The other alerts are safety concerns that can be handled after the circulation problem.

Question 10

At 0700 the nurse reviews the handoff notes for an assignment of four clients on an inpatient eating disorders unit. Which client should the nurse see first?

Accepted Answer

B: A client with bulimia nervosa who reports palpitations and has a potassium level of 2.7 mEq/L. Purging by vomiting or laxatives drains potassium from the body. A potassium level of 2.7 mEq/L is well below the normal range of 3.5 to 5.0 mEq/L, and with palpitations it means the heart muscle is already irritable. Severe hypokalemia can cause ventricular dysrhythmias and cardiac arrest, and it is a common cause of sudden death in bulimia nervosa.

This is a physiological threat to life, so this client is seen first. The nurse checks the apical pulse and rhythm, places the client on a cardiac monitor if available, and reports the level to the health care provider for potassium replacement.

Who do you see first?