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Difficulty: HardEstablishing Priorities

The charge nurse on a nephrology unit is evaluating the current status of four assigned clients. Which client requires the most immediate assessment by the nurse?

  1. A
    A client 24 hours post-transurethral resection of the prostate (TURP) receiving continuous bladder irrigation who has light pink effluent and reports bladder spasms.
  2. A client with the oliguric phase of acute kidney injury who exhibits new-onset peaked T-waves on telemetry and reports generalized muscle weakness.Answer
  3. C
    A client admitted with nephrolithiasis who reports sudden, excruciating left flank pain radiating to the groin with associated nausea.
  4. D
    A client with end-stage renal disease waiting for a scheduled hemodialysis treatment who has a blood urea nitrogen (BUN) level of 72 mg/dL (25.7 mmol/L) and prominent uremic frost.

Answer

The client with the oliguric phase of acute kidney injury who exhibits new-onset peaked T-waves on telemetry and reports generalized muscle weakness.
The correct answer identifies a client experiencing hyperkalemia, indicated by peaked T-waves and generalized muscle weakness, which is a direct consequence of the oliguric phase of acute kidney injury (inability to excrete potassium). Hyperkalemia represents an immediate Circulation (ABC) threat because it can quickly trigger fatal cardiac dysrhythmias, such as ventricular fibrillation or asystole. This client is the most unstable and requires immediate medical intervention.

Step-by-Step Solution

1
Analyze each client's presentation to identify the underlying physiological issue.
Client 1 has expected post-operative symptoms; Client 2 has signs of severe hyperkalemia; Client 3 has expected pain from a kidney stone; Client 4 has expected chronic signs of uremia.
Accurate identification of the underlying pathology is necessary before prioritizing.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
The client with peaked T-waves and muscle weakness has an acute electrolyte imbalance (hyperkalemia) threatening cardiac function (Circulation).
The ABC framework dictates that immediate threats to life must be addressed before pain, expected post-operative findings, or chronic conditions.
3
Distinguish between acute/unexpected complications and chronic/expected disease manifestations.
The hyperkalemia is an acute, life-threatening complication. The manifestations in the other three clients are expected consequences of their respective conditions or procedures.
Clients with unexpected, unstable conditions always take precedence over those with predictable, stable, or chronic symptoms.

Key Concept

Prioritization: ABC Framework and Acute vs. Chronic Conditions
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Establishing Priorities

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