A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first?
a. Client who had two bloody diarrhea stools this morning
b. Client who has been premedicated for nausea prior to chemotherapy
c. Client with a respiratory rate change from 18 to 22 breaths/min
d. Client with an unchanged lesion to the lower right lateral malleolus
ANS: A
The client who had two bloody diarrhea stools that morning may be hemorrhaging in the gastrointestinal (GI) tract and should be assessed first. The client with the change in respiratory rate may have an infection or worsening anemia and should be seen next. The other two clients are not a priority at this time.
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