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Question

Difficulty: EasyEstablishing Priorities

The nurse reviews the current status of four assigned clients. Which client requires the nurse's immediate evaluation?

  1. A
    A client with chronic obstructive pulmonary disease (COPD) who exhibits a barrel chest and clubbed fingers.
  2. B
    A client preparing for a morning colonoscopy who reports passing frequent clear, liquid stools after drinking the prescribed bowel preparation.
  3. A client receiving an intravenous cephalosporin who develops sudden facial swelling and expiratory wheezing.Answer
  4. D
    A client admitted with a deep vein thrombosis (DVT) who has unilateral calf warmth, redness, and swelling.

Answer

The client receiving an intravenous cephalosporin who develops sudden facial swelling and expiratory wheezing.
The client experiencing sudden facial swelling and wheezing is demonstrating acute signs of anaphylaxis. Using the ABC (Airway, Breathing, Circulation) prioritization framework, this represents a life-threatening airway and breathing compromise that must be managed immediately to prevent respiratory arrest.

Step-by-Step Solution

1
Evaluate the clinical presentation of each client using the Airway, Breathing, Circulation (ABC) prioritization framework.
The client receiving the antibiotic has compromised airway and breathing, while the others have stable or expected findings.
Life-threatening acute changes must always be prioritized over chronic or expected manifestations.
2
Differentiate between expected manifestations of a disease/treatment and unexpected, acute complications.
The COPD symptoms, colonoscopy prep results, and DVT signs are all expected. The facial swelling and wheezing are unexpected and life-threatening.
Clients with expected findings are considered stable and are a lower priority for immediate assessment.

Key Concept

Prioritizing acute airway emergencies over stable, expected, or chronic findings.
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Topics

Establishing Priorities

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