The nurse receives handoff report on four clients on a surgical unit. Which client should the nurse assess first?
- AA client with chronic obstructive pulmonary disease whose oxygen saturation is 90% on oxygen at 2 L/min by nasal cannula
- BA client who had an open colectomy 2 days ago, rates incisional pain 6 on a 0-to-10 scale, and is due for an oral analgesic in 30 minutes
- CA client who had a total thyroidectomy 6 hours ago and reports that the neck dressing feels tight and that swallowing is getting harder
- DA client with type 2 diabetes whose fasting capillary blood glucose is 188 mg/dL
Show answer and explanations
Answer
C
A: A saturation of 90% can be within the stated COPD oxygen target and is not the newly threatened airway. B: Postoperative pain needs care but does not outrank the evolving airway threat. C: Neck tightness and worsening swallowing after thyroidectomy suggest a compressive hematoma. D: Moderate hyperglycemia does not outrank the acute airway concern.
A
A saturation of 90% can be within the stated COPD oxygen target and is not the newly threatened airway.
B
Postoperative pain needs care but does not outrank the evolving airway threat.
C
Neck tightness and worsening swallowing after thyroidectomy suggest a compressive hematoma.
D
Moderate hyperglycemia does not outrank the acute airway concern.