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Question

Difficulty: EasyEstablishing Priorities

Following the change of shift, the registered nurse evaluates four assigned clients. Which client presentation mandates the nurse's immediate attention?

  1. A client admitted with pneumonia who exhibits acute confusion and restlessnessAnswer
  2. B
    A client with chronic obstructive pulmonary disease (COPD) who has a resting oxygen saturation of 91% on room air
  3. C
    A client with end-stage renal disease (ESRD) who reports persistent, generalized fatigue
  4. D
    A client recovering from a total hip arthroplasty who is requesting assistance with morning hygiene

Answer

The client admitted with pneumonia who exhibits acute confusion and restlessness requires immediate attention.
The correct answer identifies a client exhibiting acute confusion and restlessness in the setting of pneumonia. These are early, critical signs of hypoxia and inadequate oxygenation. According to the Airway, Breathing, Circulation (ABC) prioritization framework, an acute compromise in breathing and oxygenation must be addressed immediately to prevent rapid physiological deterioration.

Step-by-Step Solution

1
Evaluate all client presentations for acute, life-threatening conditions using the Airway, Breathing, and Circulation (ABC) framework.
The client with pneumonia has new-onset confusion and restlessness.
These symptoms are critical early indicators of hypoxia, directly threatening the client's airway and breathing.
2
Assess the remaining clients to determine if their findings are expected, chronic, or non-urgent.
The other three clients present with either chronic/expected findings (COPD with 91% saturation, ESRD with fatigue) or routine basic care needs (morning hygiene).
Chronic, expected, or routine care needs are lower priority than acute physiological changes.
3
Prioritize the most unstable client for immediate assessment.
The client with pneumonia is identified as the highest priority.
Immediate intervention is required to address potential hypoxic respiratory failure.

Key Concept

Prioritization frameworks: Airway, Breathing, Circulation (ABCs) and Acute vs. Chronic.
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Establishing Priorities

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