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Difficulty: HardAssignment, Delegation and Supervision

Following the evening shift handoff on a cardiovascular step-down unit, the nurse prepares to evaluate four assigned clients. Arrange the clients in the order they should be assessed, from highest priority to lowest priority.

  1. 1A client with unstable angina reporting retrosternal chest pain that radiates to the jaw and is unrelieved by one dose of sublingual nitroglycerin
  2. 2A client with acute decompensated heart failure receiving continuous intravenous furosemide who has a total urine output of 30 mL over the last two hours
  3. 3A client on a continuous heparin infusion for a deep vein thrombosis who is scheduled to have a routine activated partial thromboplastin time (aPTT) drawn in 15 minutes
  4. 4A client with a mechanical aortic valve replacement who is medically stable and awaiting discharge instructions regarding lifelong warfarin therapy

Answer

The correct priority sequence is: 1) the client with unrelieved chest pain, 2) the client with heart failure and oliguria, 3) the client requiring a time-sensitive aPTT draw, and 4) the client waiting for discharge teaching.
Prioritization in nursing care is guided by the ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs. Unstable clients with acute, life-threatening conditions must be assessed first, followed by clients with urgent changes in condition, then those with time-sensitive needs, and finally stable clients requiring routine care or education.

Step-by-Step Solution

1
Identify life-threatening or ABC (Airway, Breathing, Circulation) emergencies.
The client with chest pain unrelieved by nitroglycerin is experiencing active ischemia.
Active myocardial ischemia poses an immediate threat to the client's life and requires rapid assessment and intervention.
2
Identify acute physiological instability or systemic deterioration.
The client with heart failure producing only 30 mL of urine over two hours is exhibiting signs of decreased cardiac output.
Oliguria in a client receiving diuretics is a critical sign of hypoperfusion, requiring prompt evaluation, though it does not take precedence over an active myocardial infarction.
3
Evaluate remaining clients for time-sensitive tasks.
The client requiring a scheduled aPTT draw for a heparin drip is identified as the third priority.
The client is stable, but a timely blood draw is essential for safely adjusting the continuous medication infusion.
4
Identify stable clients requiring routine care or education.
The client awaiting discharge teaching represents the lowest priority.
The client is physiologically stable and waiting to go home; educational activities can be safely delayed.

Key Concept

Prioritization of Care based on Acuity and Stability
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Topics

Assignment, Delegation and Supervision

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