The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?
A.
An adult who is in Buck’s traction, and scheduled for hip arthroplasty within the next 12 hours.
B.
An older client who is receiving packed red blood cells on the third day postoperatively for colon resection.
C.
An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery.
D.
An adult one day postoperative laparoscopic cholecystectomy requesting pain medication.
The correct answer and Explanation is :
The nurse should first see Option B: the older client receiving packed red blood cells on the third day postoperatively for colon resection.
Explanation:
When prioritizing care, nurses often use the ABCs (Airway, Breathing, Circulation), along with assessing for life-threatening conditions. In this case, the client receiving a blood transfusion (Option B) presents the highest potential risk.
- Risk of Transfusion Reactions:
Blood transfusions carry a risk of transfusion reactions, including allergic reactions, febrile non-hemolytic reactions, and hemolytic reactions. These can occur during or after the transfusion and, if left untreated, may lead to life-threatening complications. The nurse must closely monitor this client for any signs of a reaction, such as fever, chills, hives, back pain, hypotension, or shortness of breath, which makes this patient a priority. - Postoperative Status:
This client is also in the postoperative period following a colon resection, which can have complications like infection, bleeding, or delayed healing. Receiving packed red blood cells suggests that the client may have experienced blood loss or anemia, which can further compromise recovery. - Other Clients:
- Option A: The client in Buck’s traction has a planned surgery in 12 hours and is stable; Buck’s traction itself is not an emergency unless there are signs of skin breakdown or circulation issues.
- Option C: The client with continuous bladder irrigation needs monitoring for urinary flow and potential clot formation but isn’t in immediate danger unless there’s a blockage or severe bleeding.
- Option D: The client who is one day postoperative from a laparoscopic cholecystectomy is requesting pain medication, which is important but not an immediate life-threatening concern.
The client receiving the blood transfusion (Option B) presents the highest immediate risk, making them the priority for the nurse’s attention.