A nurse is receiving change-of-shift report for a group of clients.
Which of the following clients should the nurse plan to assess first?
A.
client who has a hip fracture and a new onset of tachypnea
B.
client who has diabetes mellitus and an HbA1c of 6.8%.
C.
A client who has epidural analgesia and weakness in the lower extremities
D.
A client who has sinus arrhythmia and is receiving cardiac monitoring
The correct answer is:
A. Client who has a hip fracture and a new onset of tachypnea
Explanation:
Tachypnea (rapid breathing) in a client with a hip fracture could indicate a serious complication such as a pulmonary embolism, which is a medical emergency. This condition requires immediate assessment to determine if the tachypnea is related to a life-threatening issue that needs urgent intervention.
Here’s why the other options are less urgent:
- B. Client who has diabetes mellitus and an HbA1c of 6.8%: An HbA1c of 6.8% is slightly above the normal range but not an immediate concern. Regular monitoring and management adjustments are needed, but it does not require urgent assessment.
- C. A client who has epidural analgesia and weakness in the lower extremities: Weakness in the lower extremities might be a side effect of epidural analgesia, but it is not as immediately life-threatening as potential complications like pulmonary embolism.
- D. A client who has sinus arrhythmia and is receiving cardiac monitoring: Sinus arrhythmia is usually a benign condition and not an urgent concern. Cardiac monitoring is appropriate, but it does not require immediate assessment compared to potential complications associated with tachypnea.
Correct answer: A