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Difficulty: MediumEstablishing Priorities

After receiving the handoff report on a pediatric acute care unit, the nurse prepares to assess four assigned clients. Which client should the nurse evaluate first?

  1. A 3-month-old infant with bronchiolitis who has a respiratory rate of 68 breaths per minute and exhibits expiratory grunting.Answer
  2. B
    An 8-year-old child with a vaso-occlusive sickle cell crisis who is crying and reports a pain level of 9 on a 0-10 scale.
  3. C
    A 5-year-old child with Kawasaki disease who is highly irritable and has peeling skin on the hands and feet.
  4. D
    A 12-year-old child with acute glomerulonephritis who has a blood pressure of 138/88 mm Hg and produces rust-colored urine.

Answer

The 3-month-old infant with bronchiolitis who has a respiratory rate of 68 breaths per minute and exhibits expiratory grunting.
The correct answer is the infant with bronchiolitis because tachypnea (respiratory rate of 68/min) and expiratory grunting are signs of severe respiratory distress and impending respiratory failure. Using the ABC (Airway, Breathing, Circulation) prioritization framework, this acute and potentially life-threatening condition must be addressed before any other client's needs.

Step-by-Step Solution

1
Analyze the clinical presentation of the 3-month-old infant with bronchiolitis.
The infant has severe tachypnea (RR 68/min) and expiratory grunting.
Grunting is a compensatory mechanism to keep alveoli open and indicates impending respiratory failure.
2
Analyze the clinical presentation of the other three clients.
The client with sickle cell crisis has severe pain; the client with Kawasaki disease has expected irritability and skin peeling; the client with glomerulonephritis has expected hypertension and hematuria.
Identifying expected findings versus acute, unstable manifestations helps in triaging care.
3
Apply a prioritization framework (e.g., ABCs, acute vs. chronic, unexpected vs. expected) to the four clients.
The infant with respiratory distress has an acute 'Breathing' compromise, which takes precedence over pain and expected disease manifestations.
Airway and breathing compromises are immediately life-threatening and must be addressed first.

Key Concept

Prioritization using the ABC (Airway, Breathing, Circulation) framework and the principle of acute vs. expected manifestations.
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Establishing Priorities

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