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Difficulty: EasyEstablishing Priorities

A triage nurse in the emergency department receives four clients at the same time. Using the ABC (Airway, Breathing, Circulation) and Maslow's hierarchy of needs frameworks, arrange the clients in the order they should be assessed, from highest priority (first) to lowest priority (last).

  1. 1A client experiencing sudden airway swelling and stridor after eating peanuts.
  2. 2A client with active, spurting bleeding from a forearm laceration.
  3. 3A client reporting sudden, severe lower abdominal pain rated 8 on a 0 to 10 scale.
  4. 4A client waiting for discharge instructions following a resolved migraine.

Answer

The correct order of assessment is: 1) the client with airway swelling, 2) the client with spurting bleeding, 3) the client with severe abdominal pain, and 4) the client waiting for discharge instructions.
The correct sequence strictly follows the ABC framework and triage principles. The airway emergency (stridor/swelling) is the most critical and must be seen first. The circulatory emergency (spurting bleeding) follows immediately. The urgent physiological need (severe acute pain) is third, and the stable client requiring routine care (discharge teaching) is safely seen last.

Step-by-Step Solution

1
Identify the client with an immediate airway or breathing threat.
The client with sudden airway swelling and stridor is identified as having a compromised airway.
According to the ABC framework, airway is always the highest priority because lack of oxygen leads to rapid clinical deterioration and death.
2
Identify any clients with critical circulatory or perfusion issues.
The client with active, spurting bleeding has a severe circulatory threat.
Circulation is the 'C' in the ABC framework and is prioritized immediately after airway and breathing are secured to prevent hypovolemic shock.
3
Assess the remaining clients for acute, urgent physiological needs.
The client with sudden, severe 8/10 abdominal pain is prioritized next.
Acute pain is an urgent physiological need that indicates a potential underlying issue requiring prompt medical attention, taking precedence over stable clients.
4
Identify clients who are stable or require routine care.
The client waiting for discharge instructions for a resolved migraine is placed last.
Stable clients who only need routine teaching or administrative tasks can safely wait without risk of clinical deterioration.

Key Concept

Prioritization using the ABC (Airway, Breathing, Circulation) framework and Maslow's hierarchy of needs.
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Establishing Priorities

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