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Difficulty: MediumEstablishing Priorities

The nursing team has just concluded the morning shift handover. Upon reviewing the client profiles, which of the following clinical presentations necessitate an immediate priority assessment? Select all that apply.

  1. A client 2 hours post-total thyroidectomy who reports new-onset numbness and tingling around the lips.Answer
  2. A client admitted 12 hours ago with a fractured femur who suddenly develops confusion and an oxygen saturation of 88% on room air.Answer
  3. C
    A client with severe chronic obstructive pulmonary disease (COPD) who has a barrel chest and an oxygen saturation of 90% on room air.
  4. D
    A client 24 hours post-laparoscopic cholecystectomy who reports right shoulder pain rated 4 on a 0 to 10 scale.
  5. E
    A client with a mild concussion admitted overnight who is easily arousable and reports a persistent dull headache.

Answer

The clients requiring immediate priority assessment are the one reporting numbness around the lips post-thyroidectomy and the one with a femur fracture developing confusion and hypoxia.
The correct selections involve clients experiencing acute, life-threatening complications related to airway and breathing. The post-thyroidectomy client is showing signs of hypocalcemia (circumoral paresthesia), which places them at immediate risk for laryngospasm and airway loss. The client with a femur fracture is exhibiting classic signs of fat embolism syndrome (sudden hypoxia and confusion), which is a critical respiratory emergency.

Step-by-Step Solution

1
Analyze each client's presentation to determine if the findings represent an acute, life-threatening complication or an expected, chronic condition.
Two clients exhibit unexpected, acute airway and breathing complications.
The prioritization framework requires nurses to attend to acute airway, breathing, and circulation (ABC) issues before expected or chronic findings.
2
Evaluate the post-thyroidectomy client.
Numbness and tingling around the lips (circumoral paresthesia) is an early sign of hypocalcemia, which can rapidly progress to laryngospasm and airway obstruction.
The parathyroid glands can be accidentally removed or damaged during a thyroidectomy, causing an acute drop in serum calcium levels.
3
Evaluate the client with a fractured femur.
Sudden confusion and hypoxia are hallmark signs of fat embolism syndrome, a respiratory emergency.
Fat emboli from long bone fractures can travel to the pulmonary circulation, causing acute hypoxemia and neurologic changes.
4
Evaluate the remaining clients.
The COPD client, the post-laparoscopic client, and the concussion client all exhibit expected, stable findings for their respective conditions.
Clients with expected or chronic manifestations are lower priority compared to those with unexpected, unstable physiological changes.

Key Concept

When establishing priorities, the nurse must rapidly identify acute, unexpected findings that threaten airway, breathing, or circulation (ABCs) over chronic, expected, or stable manifestations.
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Establishing Priorities

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