The nurse has a multiple client assignment on the surgical unit. When beginning the shift, the nurse needs to determine which postoperative client should be seen first. Which one of the fol-lowing clients should the nurse see first?
a. The client is reported as having a BP of 90/50.
b. The client received medication for pain 10 minutes ago.
c. The client needs to be out of bed and ambulating.
d. The client requires instructions for wound care.
A
The nurse who assigns priorities to action and determines to see this client first because of a lower than normal blood pressure for a postoperative patient is using scientifically and prac-tice-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 involved in treatment delays to determine which clients have the greatest priority for care.
The client with a BP of 90/50 is not reported to be having any problems and therefore is not the priority.
The client who needs to be out of bed and ambulating is not the priority.
The client who requires instructions for wound care is not the priority.
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