The nurse works on a medical-surgical unit. Which of the following clients will require a rapid assessment? Standard Text: Select all that apply

Question

1. The client had an open appendectomy 2 days ago and is preparing to be discharged today.
2. The client was admitted to the hospital yesterday and is being treated with intravenous antibiotics for pneumonia.
3. The client has just been received from the Post Anesthesia Care Unit.
4. The nurse is new to the unit and is planning care for the four clients that have been assigned to the nurse.
5. The client begins to complain of difficulty breathing. The client's oxygen saturation level has decreased from 93% on room air this morning to 87%.

Answer 1

3,4,5
Rationale 1: The client had an open appendectomy 2 days ago and is preparing to be discharged today. The client who is postoperative day 2 and is preparing to be discharged requires a routine assessment.
Rationale 2: The client was admitted to the hospital yesterday and is being treated with intravenous antibiotics for pneumonia. The client who has been admitted to the unit the day before and is receiving effective treatment requires a routine assessment.
Rationale 3: The client has just been received from the Post Anesthesia Care Unit. The nurse should perform a rapid assessment on a client following a surgical procedure.
Rationale 4: The nurse is new to the unit and is planning care for the four clients that have been assigned to the nurse. The nurse who is new to the unit can plan care for the assigned clients by performing a rapid assessment on each of the assigned clients to help the nurse prioritize care.
Rationale 5: The client begins to complain of difficulty breathing. The client's oxygen saturation level has decreased from 93% on room air this morning to 87%. The nurse should perform a rapid assessment on a client who is in distress.