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Question

Difficulty: EasyEstablishing Priorities

A nurse on a pediatric unit is reviewing the status of assigned clients. Which of the following client findings require the nurse's immediate intervention? Select all that apply.

  1. A 6-month-old with bronchiolitis exhibiting nasal flaring and sternal retractions.Answer
  2. B
    A 4-year-old with a closed radius fracture who is crying and guarding the affected arm.
  3. A 7-year-old who is 4 hours post-tonsillectomy and is observed swallowing frequently.Answer
  4. D
    A 2-year-old with viral gastroenteritis who had one loose stool during the previous shift.
  5. E
    A 10-year-old with asthma who has clear lung sounds and an oxygen saturation of 97% on room air.

Answer

The findings requiring immediate intervention are the infant with nasal flaring and retractions, and the child who is frequently swallowing post-tonsillectomy.
The correct selections represent acute, potentially life-threatening conditions. Nasal flaring and sternal retractions are signs of severe respiratory distress (a Breathing priority). Frequent swallowing after throat surgery is a primary indicator of active bleeding (a Circulation and Airway priority). Both require immediate life-saving interventions.

Step-by-Step Solution

1
Analyze each client's presentation to distinguish between expected, stable findings and acute, unexpected complications.
Three clients have expected findings (fracture pain, loose stool in gastroenteritis, stable asthma), while two have acute abnormalities.
Prioritization requires identifying which clients are deviating from an expected baseline or experiencing a life-threatening change.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework to the acute abnormalities.
The infant with retractions has a Breathing compromise. The post-tonsillectomy child swallowing frequently has a potential Circulation (hemorrhage) and Airway compromise.
Clients with actual or potential ABC impairments are always the highest priority for nursing intervention.

Key Concept

Prioritization using the Airway, Breathing, Circulation (ABC) framework and the ability to differentiate between expected disease manifestations and acute, life-threatening complications.
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Establishing Priorities

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