A nurse has just received change-of-shift report for four clients.
Which of the following clients should the nurse assess first?
A.
A client who is scheduled for a procedure in 1 hr.
B.
A client who received a pain medication 30 min ago for postoperative pain.
C.
A client who was just given a glass of orange juice for a low blood glucose level.
D.
A client who has 100 mL of fluid remaining in his IV bag.
E.
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The Correct Answer is C
The correct answer is:
C. A client who was just given a glass of orange juice for a low blood glucose level.
Explanation: The nurse should prioritize assessing the client who was just given orange juice for a low blood glucose level. Hypoglycemia can be an immediate, life-threatening condition, and it is important to assess the client’s response to treatment promptly to ensure that the blood glucose level has increased and stabilized.
- A. A client who is scheduled for a procedure in 1 hr does require preparation, but this can typically be done after ensuring all clients are stable.
- B. A client who received pain medication 30 minutes ago for postoperative pain should be reassessed, but this can usually wait a short while as the medication takes effect.
- D. A client who has 100 mL of fluid remaining in his IV bag is not in immediate need of attention, as there is still time before the IV needs to be changed.
Prioritization in nursing involves addressing the most critical and potentially life-threatening situations first, which in this scenario is monitoring the client’s response to hypoglycemia treatment.