A nurse works on the surgical unit. After receiving the hand-off report, which client should the nurse see first?

Question

a. Client who underwent diverticula removal with a pulse of 106/min
b. Client who had esophageal dilation and is attempting first postprocedure oral intake
c. Client who had an esophagectomy with a respiratory rate of 32/min
d. Client who underwent hernia repair, reporting incisional pain of 7/10

Answer 1

ANS: C
The client who had an esophagectomy has a respiratory rate of 32/min, which is an early sign of sepsis; this client needs to be assessed first. The client who underwent diverticula removal has a pulse that is out of the normal range (106/min), but not terribly so. The client reporting pain needs pain medication, but the client with the elevated respiratory rate needs investigation first. The nurse should see the client who had esophageal dilation prior to and during the first attempt at oral feedings, but this can wait until the other clients are cared for.