After change-of-shift report, which patient should the progressive care nurse assess first?

Question

a. Patient who was extubated in the morning and has a temperature of 101.4° F (38.6° C)
b. Patient with bilevel positive airway pressure (BiPAP) for sleep apnea whose respiratory rate is 16
c. Patient with arterial pressure monitoring who is 2 hours post–percutaneous coronary intervention who needs to void
d. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 98 sec

Answer 1

ANS: D
The findings for this patient indicate high risk for bleeding from an elevated (nontherapeutic) PTT. The nurse needs to adjust the rate of the infusion (dose) per the health care provider's parameters. The patient with BiPAP for sleep apnea has a normal respiratory rate. The patient recovering from the percutaneous coronary intervention will need to be assisted with voiding and this task could be delegated to unlicensed assistive personnel. The patient with a fever may be developing ventilator-associated pneumonia, but addressing the bleeding risk is a higher priority.