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Difficulty: HardAssignment, Delegation and Supervision

A registered nurse (RN) has just received the morning shift handoff report for a group of clients on a medical-surgical unit. In which order should the RN assess the following clients? Arrange the clients from highest priority (to be assessed first) to lowest priority (to be assessed last).

  1. 1A client with an acute asthma exacerbation who is increasingly lethargic and has an abrupt cessation of previously audible wheezing.
  2. 2A client who is 4 hours postoperative following a total thyroidectomy and reports frequent swallowing and a sensation of neck fullness.
  3. 3A client receiving a continuous intravenous heparin infusion for a deep vein thrombosis who reports a sudden onset of severe lower back pain.
  4. 4A client with chronic kidney disease who is asymptomatic and scheduled to receive a routine dose of sevelamer with their morning meal.

Answer

The correct sequence of assessment is: 1) the client with asthma and a silent chest, 2) the client post-thyroidectomy with signs of a neck hematoma, 3) the client on heparin with back pain, and 4) the asymptomatic client with chronic kidney disease.
The correct assessment sequence relies on the ABC (Airway, Breathing, Circulation) framework and the principles of triage. The client with asthma is in active respiratory failure (silent chest), representing the most immediate threat to life. The client post-thyroidectomy has signs of an expanding hematoma, which is an impending airway obstruction. The client on heparin is exhibiting signs of retroperitoneal hemorrhage, a severe circulatory emergency. Finally, the client with chronic kidney disease is stable and requires only routine care.

Step-by-Step Solution

1
Evaluate all clients for immediate life-threatening conditions using the ABC (Airway, Breathing, Circulation) framework.
The client with asthma is experiencing active respiratory failure (Airway/Breathing), which is the most immediate threat to life.
Airway and breathing failure lead to cardiac arrest within minutes if not rapidly corrected. Active failure takes precedence over impending threats.
2
Identify clients with impending airway or breathing threats.
The client post-thyroidectomy has signs of an expanding hematoma (frequent swallowing, neck fullness), which threatens the airway.
An impending airway obstruction is prioritized over circulatory issues but follows an active respiratory failure in the triage hierarchy.
3
Assess the remaining clients for acute circulatory or neurological threats.
The client on heparin with sudden back pain is at high risk for retroperitoneal hemorrhage (Circulation).
Internal bleeding can lead to severe hypovolemic shock, requiring urgent intervention after airway and breathing are secured.
4
Determine the priority of the remaining stable clients.
The client with chronic kidney disease requires routine medication but is asymptomatic and stable.
Stable clients with predictable, chronic needs are always assessed after all unstable or potentially unstable clients have been managed.

Key Concept

Prioritization using the ABC (Airway, Breathing, Circulation) framework and identifying immediate life threats vs. impending threats.
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Topics

Assignment, Delegation and Supervision

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