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Question

Difficulty: MediumEstablishing Priorities

The charge nurse on a cardiac step-down unit is evaluating the current clinical status of four assigned clients. Which client presentation requires the most immediate intervention by the registered nurse?

  1. A client recovering from a femoral cardiac catheterization whose heart rate has increased from 78 to 114 beats per minute with a current blood pressure of 102/84 mm Hg.Answer
  2. B
    A client with acute pericarditis who reports intense, sharp chest pain that worsens with deep inspiration and improves when sitting upright.
  3. C
    A client admitted for heart failure management who exhibits 2+ bilateral pitting pedal edema and a 2 kg (4.4 lb) weight gain over the past three days.
  4. D
    A client with a history of chronic atrial fibrillation who is currently asymptomatic but displays a fluctuating, irregular apical pulse of 105 beats per minute.

Answer

The client recovering from a femoral cardiac catheterization who exhibits tachycardia and a narrowing pulse pressure.
The client recovering from a cardiac catheterization is demonstrating a rapidly increasing heart rate and a narrowing pulse pressure (the difference between systolic and diastolic pressure, which is only 1818 mm Hg). These are critical early signs of compensatory shock, potentially secondary to a retroperitoneal hemorrhage from the femoral access site. Following the Airway, Breathing, Circulation (ABCs) prioritization framework, this acute circulatory compromise is life-threatening and demands immediate intervention.

Step-by-Step Solution

1
Analyze the clinical presentation of the client recovering from a femoral cardiac catheterization.
The client demonstrates tachycardia (114114 bpm) and a narrowing pulse pressure (102−84=18102 - 84 = 18 mm Hg).
These are early, subtle indicators of hemorrhagic shock, potentially from retroperitoneal bleeding at the femoral access site, representing an immediate circulatory crisis.
2
Evaluate the client with acute pericarditis.
The client has sharp chest pain that changes with position and inspiration.
This is the classic, expected manifestation of pericarditis. It does not represent an acute deterioration of Airway, Breathing, or Circulation.
3
Assess the client with heart failure.
The client has pitting edema and recent weight gain.
These are expected, chronic signs of fluid volume overload, not indicating an immediate life-threatening crisis requiring instantaneous intervention.
4
Review the client with chronic atrial fibrillation.
The client is asymptomatic with a moderately elevated, irregular heart rate of 105105 bpm.
An irregular rhythm and mildly elevated rate are expected findings in chronic atrial fibrillation, and the lack of symptoms indicates current hemodynamic stability.

Key Concept

Prioritizing unexpected, acute signs of systemic instability (such as early shock) over severe but expected manifestations of a known disease.
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Establishing Priorities

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