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Difficulty: HardEstablishing Priorities

After receiving the handoff report on a cardiovascular step-down unit, the registered nurse must determine the order of initial client rounds. Which client necessitates the nurse's immediate attention?

  1. A 55-year-old client admitted for a hypertensive crisis who suddenly reports a tearing sensation in the upper back and demonstrates a 35 mm Hg systolic blood pressure discrepancy between arms.Answer
  2. B
    A 42-year-old client receiving a continuous intravenous heparin infusion for a deep vein thrombosis, whose latest activated partial thromboplastin time (aPTT) result is 120 seconds.
  3. C
    A 62-year-old client with severe chronic obstructive pulmonary disease (COPD) whose arterial blood gas reveals a PaCO2 of 55 mm Hg and an oxygen saturation of 89% on room air.
  4. D
    A 68-year-old client with a history of heart failure who has bilateral 2+ pitting pedal edema and a morning B-type natriuretic peptide (BNP) level of 850 pg/mL.

Answer

The client admitted for a hypertensive crisis who is experiencing new tearing back pain and a blood pressure discrepancy between arms is the highest priority.
The client experiencing sudden tearing back pain and a significant systolic blood pressure variance between arms is exhibiting classic symptoms of an acute aortic dissection. This is an immediate, catastrophic circulatory emergency that poses a direct threat to life and requires rapid assessment, blood pressure control, and potential surgical intervention.

Step-by-Step Solution

1
Analyze the clinical presentation of the client with tearing back pain and blood pressure discrepancy.
Identified as a suspected acute aortic dissection, a rapidly fatal vascular emergency requiring immediate medical and surgical intervention.
Airway, Breathing, and Circulation (ABC) frameworks prioritize active circulatory collapse or catastrophic bleeding risks.
2
Evaluate the client with a prolonged aPTT of 120 seconds.
Recognized as a high-risk medication situation requiring intervention, but lacking active physiological instability or current hemorrhage.
Asymptomatic laboratory abnormalities are prioritized below active, lethal physiological manifestations.
3
Assess the clients with COPD and heart failure.
Identified their findings (PaCO2 55 mm Hg, SpO2 89%, BNP 850 pg/mL, pedal edema) as expected, chronic baselines for their respective disease processes.
Expected or chronic findings are the lowest priority in triage situations.
4
Compare all clients to determine the most urgent need.
The client with the suspected aortic dissection requires the most immediate life-saving assessment.
Acute, unexpected, and life-threatening conditions supersede chronic, expected conditions and asymptomatic lab abnormalities.

Key Concept

Prioritization requires distinguishing between acute, life-threatening emergencies (e.g., aortic dissection) and urgent but asymptomatic abnormal laboratory values or expected chronic manifestations.
Estimated Time:1m 15s
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Establishing Priorities

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