The nurse receives the following report on four patients on the medical-surgical unit.Which patient will the nurse attend to first?

A) Gait unsteady, uses walker, needs 2-person assist with ambulation
B) Abdominal wound is draining foul-smelling fluid, incision margins are red, heart rate 100 beats/min
C) Blood pressure 90/50 mm Hg, heart rate 40 beats/min, rates chest pain at 8 on a 0 to 10 pain scale
D) Verbalizes history of migraine headaches, eyes closed during assessment interview

Question

Sanjay Bhatia · Accepted Answer

Final Answer : C , Explanation :  Unstable vital signs with chest pain is of the highest priority because these symptoms may be life threatening.These instabilities must be addressed at once.Although an unsteady gait places a patient at risk for falls,this answer indicates that the patient uses a walker and 2-person assist.The draining wound is infected; however,this can be addressed with medications.Infections do not usually progress rapidly (i.e.,as compared with chest pain).The wound symptoms are not immediately life threatening.A patient with a history of migraine headaches is not a priority at this time,although the patient's pain should be relieved as quickly as possible after dealing with the highest priority problem(s).

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