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Question

Difficulty: MediumEstablishing Priorities

A nurse concludes the morning report and begins prioritizing care for a group of newly assigned clients. Which client should be evaluated first?

  1. A
    A client with a history of heart failure who has 2+ pitting pedal edema and a 2-pound (0.9 kg) weight gain since yesterday
  2. A client being treated for a severe asthma exacerbation who exhibits visible intercostal retractions but has no audible wheezingAnswer
  3. C
    A client diagnosed with a deep vein thrombosis whose affected extremity is warm, swollen, and tender to the touch
  4. D
    A client 24 hours post-appendectomy who reports localized abdominal pain rated 7 on a 0-10 scale and refuses to ambulate

Answer

The client being treated for a severe asthma exacerbation who exhibits visible intercostal retractions but has no audible wheezing.
The client with an asthma exacerbation who suddenly stops wheezing despite showing signs of increased work of breathing (intercostal retractions) is experiencing a 'silent chest'. This indicates severe bronchospasm and a lack of airflow, which can rapidly lead to respiratory failure and death. Following the Airway-Breathing-Circulation (ABC) prioritization framework, this client requires immediate life-saving intervention.

Step-by-Step Solution

1
Analyze the clinical presentation of each client to determine stability and acuity.
Three clients have expected, stable manifestations of their underlying conditions, while one client shows signs of imminent respiratory failure.
Prioritization requires identifying acute, life-threatening changes over chronic or expected findings.
2
Apply the Airway-Breathing-Circulation (ABC) framework to determine the highest priority.
The client with an asthma exacerbation who has retractions but no wheezing is experiencing a critical airway and breathing compromise.
The ABC framework dictates that severe respiratory compromise takes precedence over pain, expected postoperative findings, or chronic circulatory issues.

Key Concept

Prioritizing acute, unexpected airway emergencies over expected or chronic findings
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Topics

Establishing Priorities

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