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Difficulty: MediumEstablishing Priorities

A nurse is prioritizing care for a group of clients on a pulmonary medicine floor. Which of the following clients must the nurse evaluate first?

  1. A client experiencing a severe asthma exacerbation who previously had loud, bilateral wheezing but now presents with greatly diminished breath sounds.Answer
  2. B
    A client with an acute exacerbation of chronic obstructive pulmonary disease (COPD) who has an arterial oxygen saturation (SpO2) of 89% on room air.
  3. C
    A client with a right-sided chest tube attached to water-seal drainage that exhibits gentle tidaling with each inspiration and expiration.
  4. D
    A client receiving intravenous antibiotics for community-acquired pneumonia who has a current temperature of 101.4°F (38.6°C).

Answer

The client experiencing a severe asthma exacerbation who previously had loud wheezing but now presents with diminished breath sounds requires immediate evaluation.
The correct answer describes a client experiencing a 'silent chest', a critical medical emergency in asthma. The sudden disappearance of wheezing accompanied by diminished breath sounds means the airways have become so constricted that very little air is moving through them. This indicates impending respiratory failure and requires immediate intervention to secure the airway.

Step-by-Step Solution

1
Analyze each client's clinical presentation using the ABCs (Airway, Breathing, Circulation) framework.
Identify that the client with asthma has a sudden, severe change in airway and breathing status.
The ABC framework is the primary tool for establishing immediate clinical priorities.
2
Differentiate between expected/chronic findings and acute/unexpected findings among the distractors.
Determine that the COPD client's oxygen saturation, the chest tube's tidaling, and the pneumonia client's fever are all expected findings for their respective conditions.
Chronic or expected symptoms are a lower priority than acute, unexpected physiological changes.
3
Evaluate the clinical significance of diminished breath sounds following loud wheezing in an asthma exacerbation.
Recognize that this presentation indicates a 'silent chest'.
A lack of wheezing in a previously wheezing asthma patient signifies critical airway constriction, inadequate airflow, and impending complete respiratory failure, making this the highest priority.

Key Concept

Prioritization using the Airway, Breathing, Circulation (ABC) and Acute vs. Chronic frameworks.
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Establishing Priorities

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