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Difficulty: MediumEstablishing Priorities

A nurse assumes care for four clients on an adult medical-surgical unit. Based on the principles of prioritization, arrange the clients in the order they should be assessed, from highest priority to lowest priority.

  1. 1A client 4 hours postoperative following an anterior cervical discectomy who exhibits high-pitched inspiratory stridor.
  2. 2A client with pneumonia whose systemic blood pressure has decreased from 118/76 mm Hg to 84/42 mm Hg over the past hour.
  3. 3A client with a new long-leg cast who reports unrelenting, deep aching pain that is unrelieved by prescribed intravenous opioids.
  4. 4A client with chronic heart failure who has 2+ bilateral pitting edema and a urine output of 150 mL over the last 4 hours.

Answer

The correct sequence from highest to lowest priority is: the client with stridor (Airway), followed by the client with hypotension (Circulation), then the client with unrelieved cast pain (Disability/Limb), and finally the client with heart failure (Stable/Expected).
Prioritization in nursing care is governed by the ABC (Airway, Breathing, Circulation) framework, followed by the urgency of preserving neurological function and limb viability, and finally addressing chronic or expected findings. The client with stridor has a critical airway obstruction, making them the top priority. The client with a rapid blood pressure drop is experiencing circulatory failure, the second highest priority. The client with unrelenting cast pain is showing signs of compartment syndrome, an acute limb-threatening issue. The client with heart failure is exhibiting baseline, chronic symptoms and adequate urine output, making them the most stable.

Step-by-Step Solution

1
Analyze each client's presentation using the Airway-Breathing-Circulation (ABC) framework and the acute versus chronic principle.
Identified that the postoperative client has an airway issue (stridor), the pneumonia client has a circulation issue (hypotension), the cast client has a disability issue (compartment syndrome), and the heart failure client has stable, chronic symptoms.
Establishing a baseline understanding of each client's physiological status is necessary to apply prioritization rules.
2
Identify the absolute highest priority client based on immediate threats to life.
The client with inspiratory stridor is selected as the first priority.
Airway compromise is the most rapid cause of death and always takes precedence over other physiological issues.
3
Determine the next highest priority among the remaining clients.
The client with pneumonia and a sudden drop in blood pressure is selected as the second priority.
Hemodynamic instability (Circulation) indicates a systemic, life-threatening crisis (shock) that supersedes localized limb issues or chronic conditions.
4
Differentiate between the remaining acute condition and the chronic condition to finalize the sequence.
The client with the cast is placed third, and the client with heart failure is placed last.
Acute, unrelenting pain indicating compartment syndrome threatens limb viability and requires urgent intervention, whereas the heart failure client's edema and urine output reflect a stable, chronic state.

Key Concept

Prioritization frameworks: Airway-Breathing-Circulation (ABC), Acute vs. Chronic, and Unstable vs. Stable.
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Establishing Priorities

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