The nurse receives the following report on four patients on the medical-surgical unit. Which patient will the nurse attend to first?

Question

a. Gait unsteady, uses walker, needs 2-person assist with ambulation
b. Abdominal wound is draining foul-smelling fluid, incision margins are red, heart rate 100 beats/min
c. Blood pressure 90/50 mm Hg, heart rate 40 beats/min, rates chest pain at 8 on a 0 to 10 pain scale
d. Verbalizes history of migraine headaches, eyes closed during assessment interview

Answer 1

C
Unstable vital signs with chest pain is of the highest priority because these symptoms may be life threatening. These instabilities must be addressed at once. Although an unsteady gait places a patient at risk for falls, this answer indicates that the patient uses a walker and 2-person assist. The draining wound is infected; however, this can be addressed with medications. Infections do not usually progress rapidly (i.e., as compared with chest pain). The wound symptoms are not immediately life threatening. A patient with a history of migraine headaches is not a priority at this time, although the patient's pain should be relieved as quickly as possible after dealing with the highest priority problem(s).