After receiving report on an inpatient acute care unit, which client should the nurse assess first?

Rationale for correct choices:

• Anemia: The client’s hemoglobin (9.3 g/dL) and hematocrit (30%) are both below normal, which indicates a reduced oxygen-carrying capacity of the blood, consistent with anemia.

• Blood loss: The abdominal hematoma, distension, and need for fluid bolus suggest internal bleeding after trauma, leading to a significant drop in hemoglobin and hematocrit.

• Hemodilution from intravenous fluids: The client received large volumes of IV fluids (bolus and maintenance infusion), which dilute circulating red blood cells, worsening the anemia picture.

Rationale for incorrect choices:

• Acidosis: No arterial blood gas (ABG) results are available yet, so there is no evidence to confirm a metabolic or respiratory acidosis at this stage.

• Hypovolemia: The client initially showed low blood pressure and tachycardia, but stabilization with fluids improved her vitals; the lab values specifically indicate anemia, not pure hypovolemia.

• Disseminated intravascular coagulation: PT and PTT are within normal limits, with no signs of uncontrolled clotting or bleeding, so DIC is not supported.

• Rh factor sensitization: The client is B+, but there is no mention of pregnancy or transfusion reactions that would trigger Rh-related hemolysis.

• Pregnancy: No history, findings, or labs indicate pregnancy, so this option is unrelated to the client’s current trauma and blood results.

• Hypoxia: Oxygen saturation remains 98–100% on mechanical ventilation, showing adequate oxygenation despite anemia.

• Blood administration: While the client may need transfusion, labs reflect anemia caused by blood loss and hemodilution, not from receiving blood products.

• Immune response: There are no clinical or laboratory findings of immune-mediated destruction of red cells or inflammation causing the anemia.

• Clotting cascade: Normal PT and PTT show the coagulation pathway is intact, ruling out clotting disorders as the cause of low hemoglobin and hematocrit.

• Hypoventilation: The client is mechanically ventilated with normal oxygenation, and there is no evidence of hypoventilation contributing to her anemia.

A. Irrigate conjunctiva with ophthalmic saline prior to instilling antibiotic ointment: Routine irrigation is not typically necessary unless instructed for debris removal. Over-manipulation may increase the risk of infection or injury to the healing eye.

B. Limit exposure to sunlight during the first 2 weeks when the cornea is healing: While sunglasses can protect the eyes from UV light, strict limitation of sunlight is not usually required for 2 weeks. Standard protective measures and avoiding direct glare are sufficient.

C. Avoid straining at stool, bending, or lifting heavy objects: These activities increase intraocular pressure, which can compromise the surgical site and healing process after cataract extraction. Avoiding them is critical to prevent complications such as wound dehiscence or hemorrhage.

D. Do not read without direct lighting for 6 weeks: Reading is generally safe after cataract surgery as long as the client uses appropriate lighting. There is no standard requirement to avoid reading for 6 weeks.