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Difficulty: EasyEstablishing Priorities

A nurse is reviewing the electronic health records and morning assessment data for a group of assigned clients on a medical-surgical unit. Which of the following client findings indicate a potential life-threatening complication and require the nurse's immediate attention? Select all that apply.

  1. A client recovering from a total hip arthroplasty who reports a sudden onset of dyspnea and chest pain.Answer
  2. A client admitted with an asthma exacerbation who now has significantly diminished breath sounds and no audible wheezing.Answer
  3. C
    A client with end-stage renal disease who has a morning serum potassium level of 4.6 mEq/L (4.6 mmol/L).
  4. D
    A client with a history of chronic heart failure who exhibits 1+ bilateral pitting edema in the lower extremities.
  5. E
    A client 24 hours postoperative following an open cholecystectomy who reports an incisional pain level of 4 on a 0-10 pain scale.

Answer

The client recovering from a total hip arthroplasty with sudden dyspnea and the client with an asthma exacerbation exhibiting a silent chest.
The correct options represent acute, life-threatening emergencies that prioritize Airway and Breathing. A postoperative orthopedic client developing sudden dyspnea and chest pain is highly suspicious for a pulmonary embolism. An asthma client who suddenly stops wheezing and has diminished breath sounds is experiencing a 'silent chest,' meaning airway obstruction is so severe that air is no longer moving. Both require immediate life-saving interventions.

Step-by-Step Solution

1
Analyze each client's finding using the Airway-Breathing-Circulation (ABC) framework and the principle of acute versus chronic conditions.
Two clients have acute airway/breathing compromises, while three clients have stable or expected findings.
Prioritization requires the nurse to identify life-threatening, unexpected changes first.
2
Identify the critical emergencies among the choices.
Sudden dyspnea and chest pain post-surgery indicates a potential pulmonary embolism. Diminished breath sounds without wheezing in asthma indicates a 'silent chest' and impending respiratory failure.
Both of these conditions pose an immediate threat to the clients' lives.
3
Evaluate the remaining options to confirm they are lower priority.
A potassium level of 4.6 mEq/L is normal. 1+ pitting edema is chronic and expected in heart failure. 4/10 pain is expected 24 hours postoperatively.
Expected, chronic, or normal findings do not take priority over acute, unstable conditions.

Key Concept

Prioritization is based on the ABCs (Airway, Breathing, Circulation) and identifying acute, unexpected, or life-threatening changes versus chronic, expected, or normal findings.
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Establishing Priorities

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