The nurse has received report on the assigned night-shift clients. Which client should the nurse see first ?

  • a mildly confused client due for a dressing change on a diabetic ulcer to the heel
  • an elderly, stable client who just returned from an MRI to rule out a kidney mass
  • a client whose IV pump has started beeping, indicating that the antibiotic has completed infusing
  • a client complaining of sudden warmth and pain at an appendectomy incision site 48 hours after surgery
Number 4 is correct.
Classic signs of localized infection include sudden warmth, redness, pain at the site, and swelling caused by the inflammatory process. This client should be assessed first due to the risk of infection following surgical procedures. The health care provider should be notified immediately so that lab work can be ordered and an appropriate course of treatment started. The client needing a dressing change is not as urgent as a client with infection. A stable client returning from MRI is not the priority. The client with an IV pump beeping can be seen once the health care provider has been notified. The risk of infection and subsequent complications take priority over a beeping IV pump.