A patient four hours after pneumonectomy triggers a call bell from another room. What action should the nurse take first?

A patient four hours after pneumonectomy triggers a call bell from another room. What action should the nurse take first?

• A. Tell the unit clerk to ask the client via the intercom what is needed.
• B. Investigate the reason for the call bell alarm then complete the admission assessment.
• C. Complete the postoperative admission assessment then investigate the call bell alarm.
• D. Ask a coworker to respond to the client whose call bell is alarming.

Answer: (B)

When a patient calls for help, the first priority is to assess safety and immediate needs for the current situation. Four hours after a pneumonectomy, the patient has only one lung, so respiratory status can change quickly. The call bell could indicate pain, dyspnea, inadequate oxygenation, a problem with the chest tube, or a need for assistance with turning or comfort measures. The nurse should respond promptly and perform a focused assessment to determine why the patient is calling and whether any urgent intervention is needed. This might involve checking airway status, breathing effort, oxygen saturation, lung sounds, chest tube drainage and patency if one is in place, vital signs, pain level, and level of consciousness. Only after addressing any immediate safety concerns should the nurse proceed with the postoperative admission assessment, documenting vitals, history, and other required information. Delaying direct assessment in favor of documentation or delegating the response can miss a rapidly evolving issue and compromise patient safety.

When a patient calls for help, the first priority is to assess safety and immediate needs for the current situation. Four hours after a pneumonectomy, the patient has only one lung, so respiratory status can change quickly. The call bell could indicate pain, dyspnea, inadequate oxygenation, a problem with the chest tube, or a need for assistance with turning or comfort measures. The nurse should respond promptly and perform a focused assessment to determine why the patient is calling and whether any urgent intervention is needed. This might involve checking airway status, breathing effort, oxygen saturation, lung sounds, chest tube drainage and patency if one is in place, vital signs, pain level, and level of consciousness.

Only after addressing any immediate safety concerns should the nurse proceed with the postoperative admission assessment, documenting vitals, history, and other required information. Delaying direct assessment in favor of documentation or delegating the response can miss a rapidly evolving issue and compromise patient safety.