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Difficulty: MediumEstablishing Priorities

Following the transition of care at the beginning of the day shift on a general surgical floor, the assigned nurse begins to plan the order of client rounds. Which client presentation requires the most immediate evaluation?

  1. A
    A client with an established small bowel obstruction who has 200 mL of dark brown, foul-smelling drainage in the nasogastric collection canister.
  2. A client who is 4 hours post-thyroidectomy and reports an increasing feeling of tightness and pressure around the neck.Answer
  3. C
    A client who is 2 days post-appendectomy and has developed a rigid, board-like abdomen with a low-grade fever.
  4. D
    A client recovering from a laparoscopic cholecystectomy who reports persistent right shoulder pain despite receiving prescribed analgesics.

Answer

The client who is 4 hours post-thyroidectomy reporting neck tightness and pressure must be evaluated first.
The correct answer identifies the client at highest risk for rapid physiological deterioration. Neck tightness and pressure following a thyroidectomy are cardinal signs of hematoma formation beneath the incision. Due to the anatomical location, expanding fluid and blood can quickly lead to tracheal deviation and complete airway obstruction. Using the Airway-Breathing-Circulation (ABC) framework, maintaining airway integrity is always the top priority.

Step-by-Step Solution

1
Analyze each client's presentation to distinguish between expected, stable findings and unexpected, unstable complications.
The post-cholecystectomy and small bowel obstruction clients have expected, stable findings. The post-appendectomy and post-thyroidectomy clients are experiencing unexpected, acute complications.
Effective prioritization requires first eliminating clients whose clinical presentations are stable and expected for their current diagnosis or procedure.
2
Apply the Airway-Breathing-Circulation (ABC) framework to the remaining unstable clients to determine the highest risk.
The client with a rigid abdomen has peritonitis (a severe circulation and infection issue), while the client with neck pressure post-thyroidectomy is at risk for rapid airway obstruction.
According to the ABC prioritization framework, airway patency is the highest physiological priority because the loss of an airway results in death most rapidly.

Key Concept

Airway-Breathing-Circulation (ABC) Prioritization Framework
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Topics

Establishing Priorities

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