Difficulty: Medium
Average Score: 90%
Simulated
A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?
Correct answer
D
Rationale
The correct answer is D. The nurse's priority is the client whose blood pressure dropped significantly from 138/86 mm Hg to 106/60 mm Hg. This indicates a potential issue with perfusion and could be a sign of hypovolemic shock, which is a life-threatening condition requiring immediate intervention to prevent further complications. Monitoring and addressing this client's blood pressure is crucial to prevent deterioration.
Choice A is not the priority because pain management can be addressed after ensuring the client's physiological stability.
Choice B indicates a normal progression in wound healing and does not require immediate attention.
Choice C, while showing an increase in blood glucose levels, does not pose an immediate threat to the client's health compared to a significant drop in blood pressure as in Choice D.
Choice A is not the priority because pain management can be addressed after ensuring the client's physiological stability.
Choice B indicates a normal progression in wound healing and does not require immediate attention.
Choice C, while showing an increase in blood glucose levels, does not pose an immediate threat to the client's health compared to a significant drop in blood pressure as in Choice D.