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Difficulty: HardEstablishing Priorities

During a system-wide electronic charting outage, the unit secretary hands the charge nurse a stack of freshly recorded vital sign and assessment flowsheets from the assistive personnel. Based on the documented data, which client requires the nurse's immediate bedside evaluation?

  1. A
    A client with severe chronic obstructive pulmonary disease who has an oxygen saturation of 88% while receiving 2 L/min of oxygen via nasal cannula.
  2. B
    A client with suspected pulmonary tuberculosis who has just been admitted and inadvertently placed in a standard room instead of negative-pressure isolation.
  3. A client 2 hours post-cardiac catheterization via the femoral artery whose heart rate has increased from 78 to 114 bpm and who appears newly restless.Answer
  4. D
    A client admitted with acute pancreatitis who reports constant, severe abdominal pain rated as a 9 on a 0-to-10 scale and is requesting analgesia.

Answer

The client who is 2 hours post-cardiac catheterization with a new onset of tachycardia and restlessness requires immediate bedside evaluation due to the high risk of hemorrhagic shock.
The correct answer describes a client exhibiting early signs of hemorrhagic shock. Following a femoral artery access procedure, patients are at high risk for retroperitoneal bleeding or hematoma formation. The body initially compensates for intravascular volume loss with tachycardia, and the resulting decreased cerebral perfusion presents as restlessness or agitation. This represents an acute, unexpected, and immediately life-threatening circulation problem that must be managed instantly to prevent cardiovascular collapse.

Step-by-Step Solution

1
Analyze the finding for the client post-cardiac catheterization.
Identified tachycardia and restlessness as early indicators of decreased cardiac output and potential internal hemorrhage.
The femoral approach carries a significant risk for retroperitoneal bleeding, which is a life-threatening circulation emergency.
2
Evaluate the client with suspected tuberculosis.
Determined that while this is a major infection control issue requiring prompt correction, physiological survival of another client takes precedence.
Airway, breathing, and circulation (ABC) emergencies in a deteriorating patient must be addressed before environmental safety and isolation corrections.
3
Evaluate the client with chronic obstructive pulmonary disease (COPD).
Recognized that an oxygen saturation of 88% is an expected and stable baseline finding for severe COPD.
Chronic retainers of carbon dioxide rely on hypoxemia as their respiratory drive; this does not represent an acute deterioration.
4
Assess the client with acute pancreatitis.
Identified severe pain as an expected manifestation of the acute inflammatory disease process.
Although pain management is essential for quality care, a physiological comfort need does not supersede active, life-threatening hemorrhage.

Key Concept

Prioritization using the ABCs (Airway, Breathing, Circulation) framework and recognizing the early, subtle indicators of systemic shock.
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Establishing Priorities

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