The nurse has received report on the day’s assigned clients. Which of the following clients should the nurse see first ?

  1. a client complaining of nausea and vomiting after eating breakfast
  2. a client complaining of itching and burning at the IV site while receiving normal saline
  3. a client who is post-op day 1 from a hernia repair with a pain level of 6 on a scale of 1 – 10
  4. a client who has been given the first dose of an antibiotic and complains of tingling in and around the mouth
Number 4 is correct.
Rationale: The client experiencing tingling in and around the mouth may be having an allergic reaction to the antibiotic. The nurse should immediately assess the client’s airway and breathing, as the client is at risk for the tongue swelling and blocking the airway. The other clients may be seen after assessing the client for an allergic reaction. While it is important to address the other clients’ needs quickly, the nurse always addresses potentially life-threatening situations first.