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Question

Difficulty: EasyEstablishing Priorities

A nurse is receiving the morning shift report for a group of clients on a medical-surgical unit. Which of the following clients should the nurse assess first?

  1. A
    A client with a fractured tibia requesting pain medication for an ache rated 4 on a 10-point scale
  2. B
    A client with a urinary tract infection who is scheduled to receive a routine dose of intravenous antibiotics
  3. A client with pneumonia who is experiencing new-onset shortness of breath and a respiratory rate of 30 breaths per minuteAnswer
  4. D
    A client preparing for discharge who has questions about dietary restrictions at home

Answer

The client with pneumonia who is experiencing new-onset shortness of breath and a respiratory rate of 30 breaths per minute.
The client experiencing new-onset shortness of breath and tachypnea is displaying an acute respiratory issue. According to the Airway-Breathing-Circulation (ABC) prioritization framework, physiological needs related to breathing are the highest priority and require immediate assessment to prevent clinical deterioration.

Step-by-Step Solution

1
Analyze each client's condition using the Airway-Breathing-Circulation (ABC) framework and Maslow's Hierarchy of Needs.
Identify the primary physiological or psychosocial need for each client described in the scenario.
To determine which condition poses the most immediate threat to life.
2
Compare the severity and stability of the clients' needs to establish priority.
The client with shortness of breath has an acute breathing issue (B in ABCs). The others have needs related to comfort, routine medication administration, and education.
Acute physiological changes take precedence over stable, chronic, or lower-level psychosocial needs.

Key Concept

Airway, Breathing, Circulation (ABC) Priority Framework
Estimated Time:1m 0s
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Topics

Establishing Priorities

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