Examkin

Question

Difficulty: EasyEstablishing Priorities

An emergency department triage nurse evaluates several individuals who arrived in the waiting area simultaneously. Which client condition requires the nurse's immediate intervention?

  1. A client with an acute asthma exacerbation exhibiting audible wheezing and intercostal retractionsAnswer
  2. B
    A client with a suspected ankle fracture crying and reporting a pain level of 9 on a 0 to 10 scale
  3. C
    A client with a history of type 2 diabetes reporting a morning fasting blood glucose of 142142 mg/dL
  4. D
    A client with a generalized, non-pruritic rash that has been present on the torso for three days

Answer

The client with an acute asthma exacerbation exhibiting audible wheezing and intercostal retractions.
The correct answer identifies a client exhibiting intercostal retractions and audible wheezing, which are hallmark signs of severe respiratory distress and airway narrowing. According to the Airway, Breathing, Circulation (ABC) priority framework, this client is at immediate risk for respiratory failure and requires emergent intervention.

Step-by-Step Solution

1
Evaluate all client conditions using the Airway, Breathing, and Circulation (ABC) prioritization framework.
Identify that the client with asthma is experiencing a Breathing (and potentially Airway) issue, while the others have stable or non-life-threatening conditions.
The ABC framework dictates that physiological needs related to oxygenation and perfusion must be addressed before pain, expected chronic findings, or localized symptoms.
2
Differentiate between acute, unstable conditions and chronic, stable conditions.
The asthma exacerbation is acute and unstable. The ankle fracture is acute but stable (non-life-threatening). The diabetes and rash are chronic or subacute.
Acute and unstable conditions have a higher risk of rapid deterioration and require priority intervention.

Key Concept

Prioritization based on the Airway, Breathing, and Circulation (ABC) framework
Rate this question

Topics

Establishing Priorities

More questions from this topic