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Question

Difficulty: EasyEstablishing Priorities

A nurse on an acute care unit is reviewing the clinical status of multiple assigned clients. Which of the following client situations indicate an acute deterioration requiring immediate intervention? Select all that apply.

  1. A client with a history of asthma who suddenly stops wheezing and exhibits intercostal retractionsAnswer
  2. A client with a deep vein thrombosis who reports a sudden onset of sharp chest pain and dyspneaAnswer
  3. C
    A client with chronic obstructive pulmonary disease who has an oxygen saturation of 91% on room air
  4. D
    A client with a newly applied fiberglass cast who reports mild, localized itching underneath the cast
  5. E
    A client with chronic heart failure who has 2+ pitting edema in both ankles

Answer

The clients requiring immediate intervention are the one with asthma who has a sudden cessation of wheezing (silent chest) and the one with a deep vein thrombosis who develops sudden chest pain and dyspnea (pulmonary embolism).
Clients experiencing acute, sudden physiological deterioration related to airway, breathing, or circulation take the highest priority. The cessation of wheezing with retractions indicates an airway emergency (silent chest). Sudden chest pain and dyspnea in a client with a deep vein thrombosis indicates a pulmonary embolism, which is a severe circulatory and respiratory emergency.

Step-by-Step Solution

1
Evaluate each client's clinical presentation using the Airway, Breathing, and Circulation (ABC) prioritization framework.
The client with asthma stopping wheezing has an airway/breathing compromise. The client with a deep vein thrombosis experiencing sudden dyspnea has a breathing/circulation compromise.
The ABC framework ensures that acute, life-threatening physiological conditions are addressed before stable or chronic issues.
2
Distinguish between acute, unexpected manifestations and chronic, expected findings among the remaining clients.
The oxygen saturation of 91% in COPD, mild itching under a cast, and ankle edema in heart failure are identified as expected or chronic findings.
Clients with sudden, unexpected instability always take priority over clients experiencing chronic, anticipated disease manifestations.

Key Concept

Prioritization using the ABC framework and distinguishing acute versus chronic findings.
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Topics

Establishing Priorities

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