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    Adult Health med surg proctored exam (Viterbo university)

    The nurse gets hand-off report on four patients. Which patient would the nurse assess first?

    Explanation & Rationale

    Choice A reason: A urine output of 40 mL/hr is within the acceptable range, as normal urine output is typically around 30-50 mL/hr. While it should be monitored, it does not indicate an immediate life-threatening issue requiring urgent assessment.Choice B reason: A blood pressure change from 128/74 to 110/88 mmHg may indicate potential hemodynamic instability. Although the systolic blood pressure has decreased, the diastolic pressure has increased, which can be concerning. This patient may be at risk for developing more significant blood pressure changes or other complications, making this situation the highest priority for assessment.Choice C reason: An oxygen saturation level of 94% is generally considered acceptable. While it is on the lower end of the normal range, it does not indicate an immediate life-threatening condition. Continuous monitoring is important, but it is not the most urgent situation compared to the blood pressure change.Choice D reason: A pulse change from 100 to 88 beats/min represents a decrease in heart rate but remains within the normal range for adult heart rate (60-100 beats/min). While this change should be noted and monitored, it is not as urgent as the blood pressure change that may indicate hemodynamic instability.

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