After a change-of-shift report, the nurse needs to prioritize care for four clients. Who should the nurse attend to first?

Comparing the current blood pressure reading to the preoperative value is the first step the nurse should take. This will help determine if the patient’s blood pressure has significantly dropped, which could indicate hypovolemia or shock.

Choice B rationale

Covering the patient with a warm blanket may be helpful if the patient is feeling cold or showing signs of hypothermia, but it would not address the underlying cause of the low blood pressure.

Choice C rationale

Increasing the IV flow rate might be necessary if the patient is hypovolemic, but this decision should be based on additional assessment data and physician orders.

Choice D rationale

Reassuring the patient is important, but it should not be the first action. The nurse needs to assess and address the cause of the low blood pressure.

Choice A rationale

Loosening the screws while cleaning the pin sites is not recommended. The screws are tightened to a specific pressure to ensure the halo vest is secure and provides the necessary immobilization.

Choice B rationale

The nurse should also provide education regarding changing positions at least every 2 hours to reduce pressure injuries.

Choice C rationale

Halo-vests are managed and monitored during spinal outpatient clinics and can be removed during this clinic appointment.

Choice D rationale

The halo ring should never be used to lift or reposition the client because it is directly attached to the skull. Pulling on the ring could cause serious injury or dislocation.