Answered

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The nurse receives a report on 4 clients. Which of the following clients should the nurse see first?

1. Client receiving IV vancomycin who reports discomfort at the peripheral IV site.
2. Client with a pulmonary embolus receiving continuous IV heparin infusion and warfarin who has an INR of 1.9.
3. Client 1 day postoperative receiving patient-controlled analgesia with morphine who reports itching and nausea.
4. Client receiving maintenance IV 0.9% sodium chloride with labeled tubing indicating that tubing was changed 48 hours ago.

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Sagot :

Final answer:

The nurse should prioritize seeing the client with a pulmonary embolus and a subtherapeutic INR of 1.9 first.


Explanation:

The nurse should see the client with a pulmonary embolus receiving continuous IV heparin infusion and warfarin who has an INR of 1.9 first. An INR of 1.9 is below the therapeutic range for a client on warfarin therapy, putting them at risk of blood clots. This client requires immediate attention to prevent complications.


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