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Prioritize the order in which the nurse should assess the clients, from most urgent to least urgent:

1. The 72-year-old client who was transferred 2 hours ago from the ICU following coronary artery bypass graft and has a new onset atrial fibrillation with rapid ventricular response.

2. The 38-year-old post-operative client who had an aortic valve replacement 2 days ago, with blood pressure 114/72 mm Hg, heart rate 100 beats/min, respiratory rate 28 breaths/min, and temperature 101.2 degrees Fahrenheit (38.4 degrees Celsius).

3. The 56-year-old client who was admitted 1 day ago with chest pain, receiving intravenous heparin, and has a partial thromboplastin time (PTT) due back in 30 minutes.

4. The 62-year-old client with end-stage cardiomyopathy, blood pressure 78/50 mm Hg, urinary output 20 mL/hr, and a DNR order, whose family has just arrived.

Answer :

Final answer:

The nurse should prioritize the clients in the following order, from most urgent to least urgent:

  1. The 38-year-old post-operative client who had an aortic valve replacement 2 days ago, with a temperature of 101.2 degrees Fahrenheit (38.4 degrees Celsius).
  2. The 56-year-old client who was admitted 1 day ago with chest pain and is receiving intravenous heparin.
  3. The 72-year-old client who was transferred 2 hours ago from the ICU following a coronary artery bypass graft and has a new onset atrial fibrillation with a rapid ventricular response.
  4. The 62-year-old client with end-stage cardiomyopathy, with a blood pressure of 78/50 mm Hg and a urinary output of 20 mL/hr.

Explanation:

In a cardiac step-down unit, nurses often receive a shift report for multiple clients and need to prioritize their assessments based on the urgency of each case. In this scenario, the nurse has four clients to assess and needs to determine the order from most urgent to least urgent.

  1. The 38-year-old post-operative client who had an aortic valve replacement 2 days ago, with a blood pressure of 114/72 mm Hg, heart rate of 100 beats/min, respiratory rate of 28 breaths/min, and a temperature of 101.2 degrees Fahrenheit (38.4 degrees Celsius). This client is a priority due to the recent surgery and the elevated temperature, which may indicate an infection.
  2. The 56-year-old client who was admitted 1 day ago with chest pain and is receiving intravenous heparin. The client has a partial thromboplastin time (PTT) due back in 30 minutes. This client should be assessed next to monitor the effectiveness of the heparin therapy and ensure the PTT is within the therapeutic range.
  3. The 72-year-old client who was transferred 2 hours ago from the ICU following coronary artery bypass graft and has a new onset atrial fibrillation with rapid ventricular response. This client requires assessment to monitor the cardiac rhythm and assess for any signs of hemodynamic instability.
  4. The 62-year-old client with end-stage cardiomyopathy, with a blood pressure of 78/50 mm Hg and a urinary output of 20 mL/hr. This client has a Do Not Resuscitate (DNR) order and their family has just arrived. While this client's condition is concerning, the other clients have more urgent needs that require immediate assessment.

By prioritizing the clients in this order, the nurse can ensure that the most urgent cases receive prompt attention and appropriate interventions.

Learn more about prioritizing clients in a cardiac step-down unit here:

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