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Difficulty: MediumEstablishing Priorities

A nurse is prioritizing care for a group of clients on a medical-surgical unit. Which of the following client findings mandate immediate intervention? Select all that apply.

  1. A client with heart failure who is expectorating pink, frothy sputumAnswer
  2. B
    A client with emphysema who has a resting oxygen saturation of 90% on room air
  3. A client with a recent concussion who exhibits a decrease in Glasgow Coma Scale score from 15 to 11Answer
  4. D
    A client with acute pancreatitis who reports severe, unrelenting mid-epigastric pain
  5. A client receiving an intravenous antibiotic who develops expiratory wheezing and urticariaAnswer

Answer

The clients requiring immediate intervention are the one expectorating pink, frothy sputum; the one with a decreasing Glasgow Coma Scale score; and the one developing wheezing and urticaria.
The correct answers represent acute, life-threatening airway, breathing, or circulation (ABC) emergencies. The client expectorating pink, frothy sputum is exhibiting signs of pulmonary edema, which severely compromises breathing and oxygenation. The client with a decreasing Glasgow Coma Scale score is demonstrating acute neurological deterioration that can rapidly threaten airway patency. The client developing wheezing and urticaria during an antibiotic infusion is experiencing anaphylaxis, a critical airway and circulatory emergency. These unstable clients must be prioritized for immediate care.

Step-by-Step Solution

1
Differentiate between acute, unstable conditions and chronic, expected findings among the presented clients.
The clients with pink frothy sputum, a dropping Glasgow Coma Scale (GCS), and wheezing/urticaria represent acute changes. The clients with emphysema (SpO2 90%) and pancreatitis (pain) represent chronic or expected findings.
Prioritization frameworks dictate that acute and unexpected clinical changes must be addressed before chronic or expected findings.
2
Evaluate the acute findings using the Airway, Breathing, Circulation (ABC) framework to determine the immediate priorities.
Pulmonary edema (pink, frothy sputum) and anaphylaxis (wheezing, urticaria) are direct ABC threats. A dropping GCS indicates a severe neurological decline that independently threatens airway patency.
Conditions that acutely threaten airway patency, effective breathing, or adequate circulation are the highest clinical priorities and require immediate intervention to prevent mortality.

Key Concept

Establishing Priorities using ABCs and Acute vs. Chronic Frameworks
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Topics

Establishing Priorities

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