A nurse is carrying for four clients. Which one would the nurse see first?

A. Client who is experiencing hallucinations and extreme anxiety after the use of marijuana: Hallucinations and anxiety are distressing but generally not life-threatening effects of marijuana use. These symptoms can be managed with reassurance and a calm environment once physical safety is ensured.

B. Client with a history of alcohol use complaining of insomnia and diaphoresis: These symptoms suggest early alcohol withdrawal, which can progress to serious complications like seizures or delirium tremens if untreated. However, at this stage, the client's symptoms are mild and not immediately life-threatening.

C. Client who has a respiration rate of 14 after overdosing on oxycodone (OxyContin): Although opioid overdose can cause respiratory depression, a rate of 14 indicates adequate ventilation for now. The client should still be closely monitored, but there is no immediate evidence of respiratory failure.

D. Client admitted with cocaine use who has an irregular heart rate of 142 beats/minute and a BP 186/92 mmHg: Cocaine toxicity can trigger severe cardiovascular complications. The markedly elevated heart rate and BP indicate acute sympathetic overactivity, which requires rapid stabilization and cardiac monitoring to prevent life-threatening outcomes.

A. Ask the client’s spouse if he is supposed to have a transfusion: Family members cannot reliably confirm the client’s identity. Relying on a spouse or relative could result in a transfusion error and is not an acceptable verification method.

B. Compare the name and ID number on the blood product tag with the name and ID number on the client’s ID band: Using two identifiers—full name and unique hospital ID number—is the safest and standard method to verify the correct recipient of a blood transfusion. This ensures the blood product matches the intended client.

C. Compare the unit and room number of the client with the unit and room number listed on the blood product tag: Room or unit numbers can change and are not unique identifiers. Relying on location alone may result in administering blood to the wrong patient if the client is moved or misassigned.

D. Ask the client whether his or her name is the one on the blood product tag: While confirming with the client can be helpful, it is insufficient as the sole method of identification. Clients may be confused, sedated, or unable to respond accurately.