The RN has received her client assignment for the day shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first?
A. A client who is ambulatory.
B. A client, who has a fever, is diaphoretic and restless.
C. A client scheduled for OT at 1300.
D. A client who just had an appendectomy and has just received pain medication.
Correct Answer: B. A client, who has a fever, is diaphoretic and restless.
This client’s needs are a priority. Clinical judgment and prioritization of patient care is built on the nursing process. Nurses learn the steps of the nursing process in their foundational nursing course and utilize it throughout their academic and clinical careers to direct patient care and determine priorities.
Option A: An ambulatory client would not be a priority. However, a thorough assessment should still be done to make sure that the client does not have any underlying diseases. In unfamiliar situations, patient prioritization should be approached as a structured process, highlighting risk factors that may contribute to a decline in the patient’s condition and potential interventions that can reduce the risk of adverse outcomes (Jessee, 2019).
Option C: The client does not have any emergent concerns based on the stem. Seasoned nurses are able to pull from their depth of knowledge and experience that allows them to act deductively and intuitively when prioritizing patient care.
Option D: The client has already received pain medication, therefore she is not a priority. For expert nurses, the ability to prioritize based on these processes is predominately intuitive, and tasks are completed in a prioritized manner without much conscious thought.