The nurse has a multiple client assignment on the surgical unit. On beginning the shift, the nurse needs to determine which postoperative client should be seen first. Of the following, the nurse should go to see the client who:
1. Has a documented blood pressure of 90/50
2. Was medicated for back pain 10 minutes ago
3. Has an order to be out of bed and ambulated
4. Requires instructions for wound care before discharge
ANS: 1
The nurse prioritizes actions and determines to see this client first because of a lower than normal blood pressure for a postoperative patient. This nurse is using scientifically and practice-based criteria for making clinical judgment. This is an example of following standards. The nurse uses criteria such as the clinical condition of the client, Maslow's hierarchy of needs, and risks in-volved in treatment delays to determine which clients have the greatest priority for care.
In answers 2 through 4, the client is not reported to be having any problems and therefore is not the priority.
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