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Difficulty: MediumEstablishing Priorities

While managing care on a pulmonary step-down unit, the nurse is reviewing recent clinical findings for assigned clients. Which client must the nurse evaluate first?

  1. A client recovering from bacterial pneumonia who exhibits new-onset restlessness and a narrowing pulse pressure.Answer
  2. B
    A client with chronic obstructive pulmonary disease (COPD) whose arterial blood gas reveals a pH of 7.33 and a PaCO2 of 58 mm Hg.
  3. C
    A client with a resolving spontaneous pneumothorax who has intermittent bubbling in the water-seal chamber of the chest tube.
  4. D
    A client with an acute asthma exacerbation who demonstrates scattered expiratory wheezes and an oxygen saturation of 93%.

Answer

The client recovering from bacterial pneumonia who exhibits new-onset restlessness and a narrowing pulse pressure requires immediate evaluation.
The correct answer identifies the client exhibiting new-onset restlessness and a narrowing pulse pressure because these are subtle but critical early signs of hypoxia and shock (such as sepsis). According to the ABCs (Airway, Breathing, Circulation) and prioritization principles, an acute, unexpected change indicating impending circulatory or respiratory collapse is the highest priority.

Step-by-Step Solution

1
Analyze each client's clinical presentation using the Airway, Breathing, Circulation (ABC) framework and the principle of acute versus chronic conditions.
Identified that three clients have expected or chronic findings, while one client has acute, unexpected changes.
Prioritization requires differentiating life-threatening emergencies from stable, anticipated manifestations of disease processes.
2
Evaluate the significance of new-onset restlessness and narrowing pulse pressure in the client with bacterial pneumonia.
Determined that these are early indicators of hypoxia and compensatory shock (likely septic shock).
Restlessness is often the earliest sign of impaired cerebral oxygenation, and a narrowing pulse pressure indicates falling cardiac output or increasing peripheral vascular resistance, necessitating rapid intervention.
3
Compare the acute deterioration of the pneumonia client against the manifestations of the other three clients.
The pneumonia client is prioritized over the clients with baseline COPD ABGs, expected chest tube bubbling, and typical asthma exacerbation symptoms.
Acute and unstable conditions always take precedence over chronic, expected, or stable abnormalities.

Key Concept

Prioritizing acute physiological deterioration over expected chronic manifestations
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Topics

Establishing Priorities

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