Gabbs Nursing Study Guide Graded A+

A nurse on a medical unit has just received change-of-shift report. Which of the following clients should the nurse assess first? A. A 68-year-old client who had a myocardial infarction 2 days ago and reports chest pain 4 on a scale of 0 to 10 B. A 48-year-old client who has AIDS, pneumocystis pneumonia, and a temperature of 38.3 C (101F) C. A 60-year-old client who has COPD, is receiving 2 L/min O2 via a nasal cannula, and has an oxygen saturation of 89% D. A 26-year-old female client who has pelvic inflammatory disease and is unable to void {Ans: A 68-year-old client who had a myocardial infarction 2 days ago and reports chest pain 4 on a scale of 0 to 10}44. A nurse is assessing a client who is postoperative following abdominal surgery. The client states, "I feel like my incision ripped open." The nurse notes dehiscence of the incision. Which of the following actions should the nurse take? Med Surg page 670 A. Extend the client's legs above heart level B. Place the client in a low-Fowler's position C. Instruct the client to perform the Valsalva maneuver D. Apply a dry gauze dressing to the incision